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ADOLPH RUPP- ^. D-. 

"ICH DIEN,' 
406W.34thSt.,NEWYoRK. 



7 



rs^ 



INJURIES AND DISEASES 



THE JAWS 



BY THE SAME AUTHOR. 



A Course of Operative Surgery. With 20 Plates drawn from 

Nature, by M. LfivElLLE, Coloured. Second Edition, large 8vo, 30s. 

Practical Anatomy: A Manual of Dissections. With 24 Coloured 
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A Manual of Minor Surgery and Bandaging, for the Use of 

House-Surgcons, Dressers, and Junior Practitioners. With 129 Engravings. 
Seventh Edition. 8vo, 6s. 

The Student's Guide to Surgical Diagnosis. Second Edition. 

8vo, 6s. Gd. 




•oo 





INJURIES AND DISEASES 



/^^-^--o-^-A}-^ /f O^^-t-.-^-^,, 



THE JAWS: 

THE JACKSONIAN PRIZE ESSAY OF THE ROYAL COLLEGE OF 
SURGEONS OF ENGLAND, 1867. 



CHRISTOPHER HEATH, F.R.C.S., 

HOLME PHOFESSOE OF CLINICAL SURGERY TIf UNIVERSITY COLLEGE, LONDON, AND SURGEON 

TO UNIVERSITY COLLEGE HOSPITAL ; 

CONSULTING SURGEON TO THE DENTAL HOSPITAL. 



THIRD 




PHILADELPHIA: 
P. BLAKISTON, SON & CO., 

1012, WALNUT STREET. 

1884. 



UJO 
PREFACE /^^^ 

TO 

THE THIRD EDITION. 



In the twelve years which have elapsed since the publica- 
tion of the second edition of this book, I have been able to 
add considerably to my personal experience of the subjects 
included within it. This has led in some instances to a 
modification of the views previously expressed, and espe- 
cially with regard to the pathology and treatment of multi- 
locular cysts of the lower jaw. In connection with this 
subject, I have particularly to mention the microscopic 
investigations of Mr. Frederick Eve, to whose labours I am 
much indebted ; and also to thank Mr. Eushton Parker, of 
Liverpool, for his assistance in classifying the tumours of the 
jaw according to modern pathological research. A chapter 
on the Diseases of the Temporo-maxillary Articulation has 
been added. To the successive Surgical Eegistrars of 
University College Hospital, Messrs. Beck, Godlee, Gould, 
Pepper, Burton, Silcock, Boyd and Horsley, my very best 
thanks are given for the careful records of my hospital 
cases, and the microscopic examination of numerous speci- 
mens of disease. 



Chkistophee Heath. 



86, Cavendish Square, 
February, 1884. 



PREFACE 

TO 

THE FIRST EDITION. 



" The Injuries f^nd Diseases of the Jaws, including those of 
the Antrum, with the treatment by operation or otherwise," 
having been announced as the subject for the Jacksouian 
Prize of 1867, I prepared an essay upon the subject, to 
which I had for some years devoted considerable attention ; 
and having been successful, I have printed it witli but 
slight alterations. My very best thanks are due to those 
gentlemen who, by generously placing valuable preparations of 
disease at my disjDOsal, enabled me to study the pathology of 
the subject more successfully than I could otherwise have 
done, and also to those who have kindly given me notes of 
interesting cases under their charge, or have lent me valu- 
able illustrations, of which due acknowledgment has been 
made in each instance. I venture to hope that the infor- 
mation thus brought together may be of service to- those 
under whose care similar cases may be placed. 

Cheistophee Heath. 

September, 1868. 



TABLE OF CONTENTS. 



CHAP. PAGES 

I. FEACTURE OF THE LOWER JAW 1 — 14 

II. COMPLICATIONS OF FKACTURE OF LOWER JAW . . . 15 — 32 

III. TREATMENT OF FRACTURED LOWER JAW 33 — 65 

IV. FRACTURES OF THE UPPER JAW 56 — 65 

V. GUNSHOT INJURIES OF THE JAWS 66 — 82 

VI. DISLOCATION OF THE JAW 83 — 97 

VII. INFLAMMATION, ABSCESS, PERIOSTITIS 98 — 109 

VIII. NECROSIS OF THE JAWS 110 — 126 

IX. REPAIR AFTER NECROSIS ; TREATMENT 127 — 141 

X. HYPEROSTOSIS 142 — 151 

XI. DISEASES OF THE ANTRUM 152—^177 

XII. CYSTS OF TEETH; DENTIGEROUS CYSTS 178 — 195 

XIII. CYSTS OF LOWER JAW AND MULTILOCULAR CYSTIC 

TUMOUR 196 — 213 

XIV. TUMOURS CONNECTED WITH TEETH AND ODONTOMATA 214 — 226 
XV. DISEASES OF THE GUMS — EPULIS 227 — 247 

XVI. TUMOURS OF THE PALATE 248 — 253 

XVII. EPITHELIOMA OF THE GUMS AND ANTRUM .... 254 — 259 

XVIII. NON-MALIGNANT TUMOURS OF THE UPPER JAW . . 260 — 286 

XIX. SARCOMATOUS „ „ „ . . 287 — 301 

XX. MALIGNANT ,, „ ,, . . 302 — 313 

XXI. DIAGNOSIS AND TREATMENT OF TUMOURS OF THE 

UPPER JAW 314 — 326 

XXII. NON-MALIGNANT TUMOURS OF THE LOWER JAW . . 327 — 343 

XXIII. SARCOMATOUS „ „ . „ . . 341 — 368 

XXrV. MALIGNANT „ „ „ . . 369 — 378 

XXV. DIAGNOSIS AND TREATMENT OF TUMOURS OF THE 

LOWER JAW 379 — 387 

XXVI. CLOSURE OF THE JAWS 388 — 411 

XXVII. DISEASES OF THE TEMPORO-MAXILLARY ARTICULATION 412 — 427 
XXVIII. DEFORMITIES OF THE JAWS 428 — 433 



APPENDIX OF CASES 434 — 472 



ILLUSTRATIONS 



IG. 




PAGE 


1. Fracture with over-lapping 


. after Malgaigne 


9 


2. „ with displacement 


)) 


10 


3. ,, of condyles and coronoid process . Fergusson 


12 


4. Fracture united at an angle, from St 


. George's 




Hospital Museum .... 


Original 


21 


5. „ „ (Hepburn) 


•) 


21 


6. . „ 


!> 


21 


7. Displacement with fibrous union 


. after Malgaigne 


24 


8. Fibrous union, from University College Museum Original 


29 


9. Ununited fracture after gunshot injury . . Cox Smith 


31 


10. „, „ ,, 


.) 


31 


11. Four-tailed bandage for lower jaw 


Original 


33 


12. Gutta-percha splint .... 


Erichsen 


34 


13. 


)) 


34 


14. Hamilton's apparatus 


. after Hamilton 


35 


15. Hammond's wire splint 


Original 


36 


16. „ „ . . 


)> 


37 


17. Thomas's wire-suture 


Erichsen 


39 


18.- ,. „ . . . . 


,. 


40 


19. Wheelhouse's method 




41 


20. Hayward's mouth-piece 


'b. Bill 


43 


21. Gunning's interdental splint 




44 


22. ,. „ ,. . . 




45 


23. ,. ., „ . . 




46 


24. „ „ „ . . 




47 


25. Bean's apparatus .... 


. after Hamilton 


48 


26. Lonsdale's apparatus 


B. Hill 


51 


27. „ „ modified . 


j> 


52 


28. Moon's splint .... 


Bryant 


52 


29. „ .... 


J) 


52 


30. Fracture of upper jaw 


Salter 


57 


31. Plate for ditto 


' * 5J 


57 


31a.Gunshot fracture of upper jaw . 


. Cox Smith 


71 


316. 


.. 


71 


32. Gunshot injury of face 


Dehout 


73 


33. Ununited gunshot fracture 


. Cox Smith 


78 


34. » . . M 


>j 


78 


35. Gunshot injury of face 


Dehout 


79 


36. „ of jaw 


„ 


79 


37. Silver chin .... 


• • >5 


80 


38. Dissection after loss of jaw 


• • 3> 


80 


39. Dislocation of jaw . 


Astley Cooper 


85 


40. „ „ ... 


. after Malgaigne 


86 


41. Dissection of dislocation of jaw 


Original 


87 


42. Dislocation of jaw 


. Fergusson 


88 


43. „ old . . . 


B. W. Smith 


89 




. J. Couper 


91 



ILLUSTRATIONS. 



Fia. 
45. 
46. 
47. 
48. 
49. 
50. 
51. 
52. 
53. 
54. 
65. 
56. 
57. 
58. 
69. 



Sti'omeyer's forceps . 
ISTecrosis of the alveolus 

Necrosis of intermaxillary bones 
Necrosis of lower jaw 
„ of upper jaw 
Portrait of patient 
Eepair after phosphorus-necrosis 



Hyperostosis, portrait 



after operation 



„ ,, cast of palate 

„ „ section of jaw 

60. Antrum Highmorianum 

6L „ „ . . , 

62. ,, ,, of normal size 

63. „ ,, of large size 

64. „ ,, of very small 

65. Antra of unequal sizes 

66. Antrum prolonged into malar bone 

67. ,, with vertical septum . 
68. 
69. 
70. 

71. „ ... 

72. Distension of antrum 
73. 
74. 
75. 
76. 
77. 

78. „ „ . . 

79. Cyst of lower jaw 

80. „ 



subdivided (with perforation) 



Cyst of antrum (W. Adams) 

)) » 

Cyst of teeth 



81. 
82. 
83. 
84. 
85. 
86. 
87. 



Inverted tooth . 
Dentigerous cyst (Fearn) 



,, ,, (Underwood) . 

Calcified cyst (Cartwright) 

88. Patient with dentigerous cyst . 

89. Dentigerous cyst 

90. Skeleton of cyst of lower jaw (St. Bartholomew 

91. Multilocular cyst of lower jaw . 

y<i. j> j» »» • 

93. Large cystic sarcoma of lower jaw (Author) 

94. Patient three months after . ,, 

95. Cystic sarcoma of lower jaw (Hutton) 

96. Cast of multilocular cysts .... 

97. Multilocular cystic tumour 

98. Recurrent epithelioma .... 



after Goffres 


95 


. Nicholson 


111 


). 


111 


Bryant 


114 


Tay 


116 


Hart 


118 


JJ 


118 


Savory 


129 


• 5> 


129 


■ter Hoivship 


143 


. FergussoYi 


147 


• 99 


147 


Original 


149 


• »> 


150 


• 99 


150 


GattUn 


152 


• 99 


152 


* 99 


153 


• J> 


154 




155 


• J) 


155 




156 




156 


9, 


157 


• 99 


167 


• JJ 


158 




158 


. Fergusson 


162 


j> 


170 


Original 


172 


xfter Gir aides 


173 


Original 


178 


• »> 


178 


>> 


178 


. Fergiisson 


183 


>> 


184 


» 


184 


Tomes 


186 


Original 


188 


>» 


188 


Forget 


189 


Original 


190 


Cattlin 


190 


Original 


192 


Forget 


194 


r's) Original 


198 


. B. Adams 


200 


Cusack 


201 


Original 


203 


>> 


203 


. B. Adams 


204 


Original 


208 


>> 


209 


)) 


210 



ILLUSTRATIONS. 



XI 



Fig. 




PAGE 


99. Misplaced tooth .... 


Forget 


215 


100. „ , 


>> 


215 


101. Odontoma (Fergusson) 


Tomes 


218 


102. „ 


Forget 


219 


103. „ (Author) 


Original 


222 


104 „ ,. ... 


j> 


222 


105. 


Salter 


224 


106. „ 


>> 


224 


107 


Forget 


224 


108. „ 


Tomes 


225 


109. Hypertrophy of gum (MacGillivray) 


Original 


229 


110. „ ., (Author) . 


)> 


230 


111. 


>> 


230 


112. Hypertrophy of alveolus ,, 


>> 


231 


113. Papillary tumour of gum (Fergusson) 


Salter 


234 


114 „ „ of palate (Cook) 


» 


235 


115. „ ,, ,, .section „ 


• jj 


235 


116. Epulis (Hutchinson) 


Original 


235 


117. „ myeloid (Hutchinson) . 


,, 


236 


118. „ giant-celled (Wilkes) . 


)> 


237 


119. „ (Author) .... 


>> 


238 


120. „ „ 


>» 


241 


121. „ case of Mary Griffiths . 


lAston 


242 


122. „ „ „ . . . 


• ' » 


243 


123. Cross-cutting forceps 


jj 


245 


124 „ „ . . . . 


)> 


245 


125. Bone-forceps 


Fergusson 


246 


126. „ „ 


>. 


246 


127. Tumour of hard palate (Author) . 


Original 


250 


128. Epithelioma of gum 


Fergusson 


255 


129. Fibrous tumours of upper jaw. 


Liston 


262 


130. Ann Struther before operation 


' j> 


263 


131. „ „ after operation . 


)» 


263 


132. Mrs. Frazer 


,. 


264 


133. Large recurrent enchondroma (Author) 


Original 


270 


134 Osseous tumour (Dupuytren) 


after V. cle Cassis 


278 


135. „ „ „ . . . . 


>j 


278 


136. „ „ (Fergusson) . 


Original 


281 


137. „ „ (Dnka) . . f 


Pathological Society 


284 


138. Myeloid of upper jaw . . . . 


Canton 


293 


139. Medullary sarcoma (Craven) . 


Original 


303 


140. „ „ 


j» 


305 


141. Doiible medullary sarcoma (Author) 


., 


306 


142. Medullary sarcoma of both jaws „ 


» 


307 


143. Epithelioma of antrum „ 




311 


144. Gensoul's incision . . . . . 


Fergusson 


316 


145. Lizars' ,, 


99 


317 


146. „ „ 


' 99 


317 


147. Scar of face . ' 




318 


148. Incisions on face 


Liston 


319 


149. Saw 


Fergusson 


320 


150. Lion forceps 


)> 


320 


151. Fibrous tumour of lower jaw (University 


College) Original 


327 


152. „ „ „ . . . . 


S'pencer Wells 


328 



Xll 



ILLUSTRATIONS. 



Pig. 

153. 

154. 

155. 

156. 

157. 

158. 

159. 

160. 

161. 

162. 

163. 

164. 

165. 

166. 

167. 

168. 

169. 

170. 

171. 

172. 

173. 

174. 

175. 

176, 

177. 

178. 

179. 

180. 

181. 

182. 

183. 

184. 

185. 

186. 

187. 

188. 

189. 

190. 

191. 

192. 

193. 

194. 

195. 

196. 

197. 

198. 

199. 

200. 

201. 

202. 

203. 

204. 



Fibrous tumour of lower jaw . . . Spencer Wells 
Fibrous tumour between plates (King's Uollege) Original 
Large fibrous tumour (Fergusson) 

Upper jaw of ditto 

Recurrent enchondroma of lower jaw 



Lawson 

Original 

Syme 

Original 

Lawson 



Ivorj^ exostosis of lower jaw (South) 

.. ' (Author) . 
Large osteo-sarcoma of lower jaw . 
Patient, after its I'emoval 
Large osteo-sarcoma of lower jaw (Author) 

,, ,, after removal 

Recurrent fibroid of lower jaw 

Myeloid tumour of symphysis (Craven 

,, „ „ section of „ 

Myeloid tumour of lower jaw . . . Fergusson 

,, ,, of both sides of jaw (Author) . Onginal 
Patient after operation .... 

Chondro-sai'coma of lower jaw (Author) ,, 

Ossifying sarcoma „ ,, ,, 

Girl, after removal of cancer of lower jaw „ „ 

Epithelioma of chin ,, . ,, 

Epithelioma of gland attached to jaw .. ,, 

Gag for mouth (Hutchinson) .... ,, 

Incision for removal of lower jaw . . . Fergusson 

Tumour of centre of lower jaw ... „ 

Incision for removal of lower jaw ... „ 

Cast of misplaced wisdom-tooth . . . Weiss 

Closure of jaws by cicatrices (Author) . . Original 

Effects of Esmarch's operation ... ,. 

Closure of jaws and cicatrix of cheek (Author) ,, 

Effects of operations ..... ,, 

Closure of jaws by cicatrices .... Weiss 

Shields for application to gums (Clendon) . Original 

Patient to whom these had been fitted (Holt) . ,, 

Diseased temporo-maxillai-y joint ... „ 

Rheumatoid arthritis of condyles ... ,, 



,, ,. glenoid cavity . ,, 

Hypertrophy of neck and condyle (McCarthy) ,, 

Patient with hypertrophy of neck (Author) . ,, 

Treatment of temporo-m axillary arthritis (Goodwillie) 

,, fibrous ankylosis ,, 

Oral speculum ,. 

Spiral spring ,. 

Deformity of maxilla from cicatrix of burn . Tomes 

Deformity of jaws from cancrum oris . . Ha^nnson 
Same patient after operation .... ,, 

„ ,, after second operation . , „ 



PAOX 

329 
329 
331 
332 
338 
339 
341 
342 
347 
347 
349 
350 
354 
355 
358 
358 
360 
361 
361 
363 
365 
370 
375 
378 
381 
383 
385 
385 
388 
401 
401 
402 
402 
406 
407 
407 
413 
416 
416 
416 
417 
418 
419 
420 
422 
423 
424 
424 
430 
431 
432 



THE 



INJURIES AND DISEASES OF THE 
JAWS. 



CHAPTER I. 

FT?ACTURE OF THE LOWER JAW. 

Fkactuee of the lower jaw is usually the result of direct 
violeuce, though Professor Pancoast met with a case in 
which fracture of tlie neck of the Lone had resulted from a 
violent fit of coughing, in an old man upwards of seventy 
years of age. (Gross's " Surgery," p. 964.) Blows received 
on the jaw in fighting or a kick from a horse are the most 
common causes of the accident; hut falls from a height 
upon the face also produce some of its most serious forms, 
owing to the commiiuition resulting. The unskilful appli- 
cation of the dentist's '' key" has heen known to cause a 
complete fracture of the bone, but more frecpiently in former 
years than at the present time, when that instrument has 
been almost entirely superseded by the forceps. 

Practures of the alveolus are frecpiently unavoidable 
during the extraction of the molar teeth, even in the most 
skilful hands, since the position assumed by the fangs is 
occasionally such that extraction without displacement of 
the bone to some extent is impossible. These cases 
ordinarily give, however^ little inconvenience, since the 
removal of the alveolus only liastens the absorption which 
must necessarily ensue upon the removal of the teeth, 
unless indeed the fracture should be so extensive as to affect 
tlie alveoli of the neighbouring teetli, in whicli case exfolia- 



2 FRACTURE OF THE LOWER JAW. 

tion of a troublesome character may be produced. Unavoid- 
able accidents of this kind have on several occasions been 
made the ground for legal proceedings against the operator ; 
but most unfairly so, since the exercise of the greatest skill 
and care cannot on all occasions prevent mishaps due to the 
natural conformation of the parts. 

On this subject, which is of considerable interest to those 
practising dental surgery, I may quote a passage from a 
paper in the " Dental Cosmos," by Dr. J. riichardson, 
illustrating the difficulty wliicli may be met with. He 
says : — 

" I have never come to regard extracting teeth as an 
operation free from liability to grave complications. I seize 
hold of a tooth to-day with more misgiving, with more 
caution, than I did the first year of my practice. Eleven 
years' experience may be supposed to have given me some 
confidence and expertness in this operation, yet with each 
year's added experience the operation grows in importance, 
and dictates greater vigilance and prudence. 1 feel my 
way through the operation with more and more caution, 
guard every movement with greater circumspection, and 
magnify my skill more and more with every success. 
Through eleven years my experience has been free from 
serious accident, but the catastrophe came at last when T 
had no possible reason to expect it. 

" Within the past two months I fractured the inferior 
jaw severely in attempting to remove the anterior right 
inferior molar. It was in this way. The patient was a lady 
about twenty-five years of age. The crown of the tooth 
was much decayed, but I had a firm hold upon the neck. 
Alternate lateral traction was made upon the tooth, mode- 
rately at first, l)ut increasing at every movement of the 
forceps. There seemed to be complete immobility of the 
tooth until the instant of its giving way, which it did with 
the outward movement of the forceps. I comprehended in- 
stantly, from the enlargement of the gum below the processes, 
that a fracture of the maxilla had occurred. On examination 
1 found the detached portion adhering firndy to the fangs 



POSITION OF FRACTURE. 3 

of the tooth, and extending antero-posteriorly about an 
inch and a quarter, and in depth about three fourths of an 
inch or more. I made no further attempts to remove 
either the tooth or fragment of bone, but pressed them 
firmly back to their places, and directed the patient to keep 
the mouth persistently closed. I hoped for a reunion of the 
fractured parts." — British Journal of Dental Science, August, 
1863. 

Mr. James Salter, in his valuable work on " Dental 
Pathology and Surgery" ( 1874) devotes a chapter to " The 
casualties which may arise in the operations of tooth- 
extraction," in which he mentions that, in extracting an 
incisor tooth from the upper jaw, the whole mass of bone 
corresponding to the intermaxillary bones broke away, 
and was merely held in place by the soft tissues. 
Fortunately the bone reunited without an untoward 
symptom. Mr. Salter also refers to a case in which a most 
able operator broke the horizontal ramus of the lower jaw 
comj^letely through, in extracting a tooth with the forceps. 

Gunshot injuries of the face may produce the most ter- 
rible injuries of the lower jaw, by splintering and removing 
large portions of it ; and the mere explosion of gunpowder 
in its immediate neighbourhood, as when a pistol is fired 
into the mouth by a would-be suicide, will produce a fracture 
of the bone. (See chapter on " Gunshot Injuries.") 

Fractures of the lower jaw are remarkable from the fact 
that they are almost always comijound towards the mouth, 
though the skin is rarely involved except in gunshot injuries. 
The fibrous tissue of the gum being very inelastic, tears 
readily when the bone is broken across, and thus the saliva 
and the air come in contact with the fractured surfaces. 
This statement only applies, however, to fractures of the body 
of the bone, for when the ramus, or still more when the 
coronoid process or condyle is broken, the bone is too deeply 
seated for the injury to extend into the mouth. 

Fracture may occur at various points in the lower jaw, 

* and the body of the bone is the portion most frequently 

injured (in 40 out of 43 cases recorded by Hamilton) ; the 

B 2 



4 FRACTURE OF THE LOWER JAW. 

ramus from its position aud coverings being much less liable 
to injury except from extreme violence, such as the passage 
of a wheel over the face or a gunshot injury. The coronoid 
process is occasionally broken off obliquely, and the neck of 
the jaw has been repeatedly broken on one or both sides of 
the bone in cases subjected to great violence. 

In the l)ody of the jaw the fracture appears to occur most 
frequently in the neighbourhood of the canine tooth, this 
position being determined probably by the greater depth of 
its socket, and the consequent weakness of the bone at that 
point ; but the fracture may happen at any other point, and 
has been known to occur exactly at the symphysis in cases 
too old to admit of separation of tlie two portions of tlie 
bone. Of the forty cases of fracture of the body recorded 
by Hamilton, four were perpendicularly through the symphy- 
sis, and eighteen of the remainder were known to be oblique, 
whilst of the whole number no less than thirteen were 
examples of double and triple fractures. In twenty ex- 
amples of fracture through the body, not including fracture 
of the symphysis, the line of fracture w^as fourteen times at 
or very near the mental foramen ; twice between the first 
and second incisor; three times behind the last molar; and 
once between the last two molars. 

The line of fracture, except at the symphysis, is usually 
oblique, and, according to Malgaigne, the thickness of the 
bone is also divided obliquely, so that generally the fracture 
is at the expense of the outer plate of the anterior fragment 
and the inner plate of the posterior fragment, though this 
rule is not without exception. 

It is impossible to gather any reliable details respecting 
the position of recent fractures of the lower jaw occurring 
in the London hospitals ; and as this fracture is rarely a 
fatal accident ^)fr se, the hospital museums contain com- 
paratively few specimens. An examination of those, how- 
ever, yields the following results : — 

The College of Surgeons possesses no specimen of recent 
fracture of the lower jaw, and only a doubtful one of united 
fracture near the angle (880). 



MUSEUM SPECIMENS OF FRACTURE. 5 

aS'^. Bartholomew's Hos2ntal possesses one specimen of frac- 
ture of the lower jaw (i. 897)/' showing a fracture on the right 
side, which extends obliquely through the bone between the 
canine and bicuspid teeth and passes through the mental 
foramen." 

St. Thomas's Hospital has one recent and moist specimen 
(27) — '^A comminuted fracture of the lower jaw. The 
bone is fractured near the symphysis and near to both 
angles, so as to expose the nascent pulps of the last molar 
teeth. The inferior maxillary nerves are not lacerated." 

Guy's Hospital has only one specimen (1091,^*^) — "A 
lower jaw having a doubtful fracture (united) on the left 
side at the angle." 

King's College Museum is very rich in recent fractures, 
having no fewer than four. 

1. A fracture between the incisor teeth, running obliquely 
to the left at the expense of the external plate of the left 
segment. The right coronoid process is broken off obliquely 
downwards from the sigmoid notch, and the necks of both 
condyles are fractured obliquely. This is the preparation 
figured by Sir William Fergusson in his " Practical Surgery," 
p. 521, and was taken by him from a patient who fell from 
a great height, and received fatal injuries. (Fig. 3.) 

[This preparation corresponds very closely to that described 
by M. Houzelot, where, in consequence of a fall from a height, 
there were produced fi'actures of the symphysis, of both 
condyles, and of hoth coronoid processes. (Malgaigne, p. 
323.)] 

2. Is an example of double fracture of the body of the 
jaw. On the right side the fracture runs between the lateral 
incisor and the canine tooth obliquely backwards, at the 
expense of the external ]3late of the posterior fragment. On 
the left side the fracture extends from the posterior socket 
of the third molar tooth (which was broken at the time, 
leaving the anterior fang in situ), obliquely backwards, at 
the expense of the outer plate of the anterior fragment. 

This was from a man who was struck on the jaw with the 
fist, and died of dcliriurn tremens in King's College Hospital 



6 FBACTUEE OF THE LOWER JAW. 

in 1857, whilst the author was Sir William Fergussou's house- 
surgeon. 

3. Is an example of double fracture of the body, and of 
fracture of both condyles. On the right side there is, in 
front of the last molar tooth, a fracture running obliquely 
forwards and then backwards, thus >, the upper division 
being at the expense of the outer plate of the posterior frag- 
ment; and the lower at the expense of the outer plate of the 
anterior fragment. On the left side a very oblique fracture 
runs forward from the front of the second molar tooth, 
which is broken. A part of the external plate has been 
broken off and is wanting. The necks of both condyles are 
broken obliquely downwards and inwards. 

The preparation is from a woman who threw herself out 
of window and fell forty feet. 

4. Is an example of comminuted fracture at and to the 
right side of the symphysis. The left half of the bone is 
cut nearly vertically through the socket of the left lateral 
incisor. The right half is cut very obliquely from the 
canine tooth at the expense of the inner plate, and the 
fragments would complete the missing portion of alveolus. 

University College Museum is also very rich in injuries of 
the jaw, having four specimens of recent fractures ; one of 
bony union; and one of fibrous imion. All the recent 
specimens show a fracture in the neighbourhood of the 
symphysis, which no doubt influenced Mr. Erichsen in the 
opinion he has expressed as to the usual position of fracture : 
" I have seen fractures most frequently in the body of the 
bone near the symphysis, extending between the lateral 
incisors, or between those teeth and the canine. The 
symphysis itself is not so commonly fractured, the bone 
being thick in this situation. The angle is frequently broken, 
but the neck and coronoid process rarely give way." (" Science 
and Art of Surgery," p. 264.) 

1. Is a vertical fracture through the symphysis, with a 
horizontal fracture running through the alveolus on the right 
side, separating the j)ortion containing the right lateral 
incisor, canine, and first bicuspid teeth. 



MUSEUM SPECIMENS OF FEACTUEE. 7 

2. Shows a fracture running at first vertically, and then 
slightly obliquely to the left through the socket of the left 
lateral incisor. The neck of the left condyle is broken off 
obliquely and very low down, so that the fissure runs down- 
wards and backwards in a line with the posterior border of 
the coronoid process. 

3. Is a vertical fracture through the symphysis, with a 
portion of dried integument adhering. Both condyles are 
broken off obliquely. 

4. Is a remarkable example of multiple and comminuted 
fracture. One fracture runs obliquely forwards in front of 
the left first molar tooth into the mental foramen. A 
second fracture runs vertically between the right incisor 
teeth. A third fracture runs very obliquely from the last 
molar on the right side down to the lower border of the bone, 
opposite the canine tooth. This is met by a fourth fracture 
running obliquely backwards in front of the first molar tooth 
of the same side. The lower border of the bone in the 
mental region is broken off and comminuted into numerous 
fragments, one of which contains the mental foramen of tlie 
right side. The left condyle is also broken off obliquely. 

5. Is an example of united fracture of the jaw in the 
right molar region, with loss of all the teeth on the right 
side except the last molar. The fracture was apparently 
oblique, and is somewhat irregularly united by bone, with 
the result of contracting the alveolar arch, so that the left 
lower teeth have been thrown inside those of the upper jaw ; 
and both having been exposed to extra attrition, owing to 
tlie absence of teeth on the opposite side, are much worn 
away, the lower on their outer and the upper on tlieir inner 
surfaces. 

6. Is a wet preparation, showing fibrous union of the 
jaw beyond the right canine tooth, a great part of the body 
of the bone in that situation being wanting. Hence it was 
probably a case of comminuted fracture, with exfoliation of 
a portion of bone. (Fig. 8.) 

*S'^. Gcorycs Hospital Museum contains one remarkable 
specimen of united fracture of the lower jaw (i. 38). The 



o FRACTURE OF THE LOWER JAW. 

fracture lias taken place to tlie right of the symphysis, and 
there has been a loss of substance, from comminution pro- 
bably, so that the two halves of the body of the bone meet 
at an acute angle, all the teeth of the right side in front of 
the bicuspid being wanting. There are small outgrowths of 
bone both in front and behind in the neighbourhood of the 
fracture, which is irregularly united, leaviiig a hole in the 
middle of the union like the socket of a tooth. The right 
mental foramen is much smaller than the left, the line of 
fracture being apparently close in front of it. The sigmoid 
notches of this jaw are unusually large. (Fig. 4.) 

In the catalogue of St. George's Museum is an account of 
a lower jaw fractured through the base of the coronoid 
process and through the neck of the condyle, in which the 
lower fragment had been displaced into the meatus auditorius 
externuS; separating the cartilaginous from the osseous por- 
tion for nearly half its circumference. The preparation 
has, however, unfortunately disappeared. 

The London Hospital Museum contains one specimen of 
recent fracture of the lower jaw. A fracture extends 
obliquely backwards between the second and third molar 
teeth to the IcJ't side, the external and internal plates of the 
bone being equally iuA'olved. There is also an oblique 
(downwards and backwards) fracture of the neck of the rifjld 
condyle. 

The Museums of Westminster, Middlesex, Charing Cross, 
and St. Mary's Hospitals contain no specimens of fractured 
lower jaw. 

Bijm'ptoms. — These are ordinarily well marked. Since even 
in simple vertical fracture of the symphysis the patient will 
be conscious of pain and slight crepitus on pressing the 
jaws together, and the surgeon will readily perceive the 
irregularity of the teeth due to alteration in the level of 
the fi'agments. The position of a patient with fracture of 
the jaw is very characteristic, since he endeavours to support 
and steady the fragments with his hands in the most careful 
manner, and his anxiety for relief is often most ludicrously 
complicated by his inability to explain by Avord of mouth 



OVER-RIDING OF FRAGMENTS. 9 

what liis ailment is. Where the laceration of the gum has 
permitted displacement of the fragments, manipulation on the 
part of the surgeon is unnecessary for the establishment of 
the diagnosis ; but when any doubt exists he should grasp 
the jaw on each side with the forefingers introduced into 
the mouth, and will have no difficulty in perceiving the 
movement and crepitus between the fragments. 

When a single fracture occurs on one side of the median 
line, the smaller fragment is liable to displacement by mus- 
cular action, being drawn outwards and at the same time a 
little forwards, so as to overlap the larger fragment. This 
is due to the action of the temporal and masseter muscles, 
but principally to the latter, and is favoured by the generally 
oblique direction of the line of fracture and consequent 

Fig. 1. 




tendency of the bones to override, as pointed out by 
Malgaigne. (Fig. 1.) This is well seen in the fracture of the 
left side in specimen 3 of the King's College collection, and 
during life the deformity was well marked. Mv. Lawson 
was good enough to show me a case recently in which union 
of a similar fracture had taken place, and in which, notwith- 
standing every care, very considerable permanent displace- 
ment of the framient had occurred. An instance of the 
obliquity of the fragment being reversed is given by 
Dr. Kmloch in the American Journal of Medical Sciences for 
July, 1859. Here the patient, who was fifty years of age, 
met with a compound fracture of the right side of the jaw, 
in front of the masseter muscle. " The line of fracture divided 



10 FRACTURE OF THE LOWER JAW. 

the boue obKqiiely through its thickness, the obliquity being 
at the expense of the external plate of tlie small posterior 
fragment, and of the internal j^late of the large or anterior 
fi'agment. The displacement was singular and marked. 
The small fi-agment i)rojected inwards and slightly upwards 
into the ca\'ity of the mouth. The Large fragment rode the 
small one, having retreated downwards and backwards, and 
its extremity, which was somewhat pointed, could be felt 
externally under the integument." 

In double fractures of the body of the jaw, one being on 
each side of the median line, the displacement is necessarily 
greater, since the muscles attached to the chin tend to draw 
the central loose piece downwards and backwards towards 
the liyoid bone, whilst both lateral portions are drawn for- 
wards and outwards, as described in the previous paragTaphs. 
When, as is probably the case in most instances of the 
kind, the obliquity of the fracture is the same on the two 
sides — i.e., at the expense of the outer surface of both ex- 
tremities of the central fragment, no difhculty is experienced 
in reducing the fracture, and it is only necessary to see that 
the posterior fragments are sufficiently approximated to the 

Fig. 2. 




central portion ; but when, as in specimen 2 of King's College, 
the obliquity is different on the two sides, the fracture being 
at the expense of the outer plate of the posterior fragment 
on the right side, and the reverse on the left side (consequent 
no doubt upon the blow ha\iug been struck to the left of the 
median line), it is obvious that great difficulties will be en- 



DOUBLE FRACTUHE OF THE JAW. 11 

countered Ijotli in reducing and maintaining the apposition 
of the fragments, as indeed was the case with the patient in 
question. 

Malgaigne records an ahnost similar case in which reduc- 
tion coukl not be effected. " The middle fragment, which 
was strongly drawn downward and backward, was easily 
brought forward nearly to a level with the other two, but 
when it came close to that on the right side it seemed to 
catch against its posterior surface, as is seen in the figure 
(fig. 2), and no efibrt could disengage it. On post-mortem 
examination the right fragment in its upper half was bevelled 
at the expense of the external surface, the middle one at the 
corresponding part at the expense of its internal face. This 
bevelled edge opposed an almost insurmountable obstacle to 
its disengagement ; there was an overlapping of the edges 
of which one would have no idea. And even after death we 
found that, to effect the reduction, it was necessary to carry 
the middle portion downward and forward, so as to carry it 
first below and then in front of the other." 

An extraordinary example of double fracture of the jaw 
was brought before the Edinburgh Medico-Chirurgical 
Society on the 20tli of November, 1861, by Dr. Struthers, 
being from a man, at. 19, who in Australia was caught by 
the coulter of liis plough, "when a great part of his jaw was 
broken off and torn away. The specimen embraced the 
entire body of the bone and more than half of the right 
ramus, which had been fractured obliquely backwards and 
downwards from the root of the coronoid process to the 
middle of the posterior edge. On the left side the fracture 
extended obliquely across the angle, from behind the socket 
of the second molar tooth to just in front of the angle. 
The patient recovered. {Edinburgli Medical Journal, 
December 1861.) 

Fracture of the ramus is usually produced by some crush- 
ing force, such as the wheel of a carriage, as in a case 
recently under my care, and the bruising of the soft parts 
is therefore considerable. But little displacement ordinarily 
occurs, owing to the deep situation of the bone, and the 



12 FRACTURE OF THE LOWER JAW. 

fact that it is well supported on each side by the masseter 
and internal pterygoid muscles. In the case alluded to 
under my own care, the i)atient was a boy of twelve, and the 
prominent symptom was the projection of the lower incisors 
beyond the upper jaw, with slight displacement towards the 
injured side. But when there is much laceration and loss 
of substance, as in gunshot injuries, the upper fragment 
is apt to be tilted forward by the temporal muscle, as was 
noticed in a case under my own care, which will be found 
in the Appendix (Case III.). Pain is referred to the part, 
and on passing the finger well bacJc into the fauces, irre- 
gularity and crepitus may be detected when the patient 
moves the jaw. 

Fracture of the neck of the condyle is not so rare an 
accident as has been stated by some authors, judging from 
the number of museum specimens of the accident which exist. 
Fig. 3, from Sir William Fergusson's " Practical Surgery," 
shows very well the ordinary appearance of the fracture, 
though in some specimens the line of fracture is more obliquely 

Fig. 3. 




placed. This is well seen in specimen 3 in University College 
Museum, where the left condyle is broken off so obliquely 
and so low down that the line of fracture runs downwards 
and backwards from the middle of the sigmoid notch. The 
cause in all the recorded cases is the same — viz., a fall from 
a considerable height. The symptoms are obscure, there 
being pain and difficulty of movement on the afiected side, 
and crepitus perceived by the patient. The condyle is 



FHACTURE OF THE NECK. 1 3 

drawn inwards and forwards by the pterygoideus externus, 
as can be ascertained by passing the finger into the month, 
and the jaw-bone is apt to become slightly displaced, so that 
the cliin is turned towards the affected side and wot from it, 
as is the case in dislocation. 

Dr. Fountain has recorded in the New York Medical 
Journal, January, 1860, a case of fracture of the neck of 
the left condyle with fracture througli the body on both sides, 
caused by a fall from a height, in which the following 
sym]3toms were present. The jaw was displaced backwards 
and laterally on the left side — a displacement which was 
temporarily rectified as long as traction was made at the 
symphysis, which the connexions of the middle fragment 
with the membranous and muscular tissues permitted. As 
soon as this traction was removed the lateral deformity was 
reproduced, and every contrivance resorted to failed to main- 
tain a permanent reduction of the fracture of the neck, 
until the upper and lower teeth were wired together so as 
to keep up traction on the lower jaw. The case did well, 
and recovered without any deformity. 

When double fracture of the neck occurs, the violence 
must have been so great as in most cases to lead shortly 
to fatal results, but M. Berard has recorded a case in which 
the double fracture did not at first lead to any displacement, 
but on the fifth day convulsions ensued, which led to con- 
siderable displacement and subsequent death. 

Watson, of New York, has moreover recorded a case of 
recovery in the person of a man who fell from the yard- 
arm of a vessel, breaking his thigh and arm bones and both 
condyles of the lower jaw, with the following symjjtoms : — 
" His face was somewhat deformed by the retraction of the 
chin ; the mouth could not be opened so as to protrude the 
tongue to any great extent beyond the teeth, and the teeth 
of the upper and lower jaw could not be brought into 
contact. In attempting to move the jaw the patient ex- 
perienced pain and crepitation just in front of the ears ; 
the crepitation could be easily felt by placing the fingers 
over the fractured condyles. Nothing was done for the 



14 FRACTUHE OF THE LOWER JA.W. 

fractures of the jaw. In a few M^eeks the rubbing of the 
broken surfaces and attendant soreness ceased to trouble 
him ; but the shape of the jaw and difficulty of opening 
the mouth to any great extent still remained unaltered." 
[Neiv York Journal of Medicine, October, 1840.) 

Eeduction of a fracture of the neck of the jaw, should 
complete displacement have occurred, can only be effected 
by acting upon the condyle and the jaw at the same time. 
The finger carried far back in the mouth should throw the 
condyle out, whilst the jaw is brought into its proper 
relation with the other hand. The fragments must then be 
pressed firmly together, and against the glenoid cavity, with 
a bandage. Pdbes, to whom this plan is due, applied it 
with success. (Malgaigne.) 

Fracture of the coronoid process is a rare accident. Thus 
Hamilton says that Houzelot's case is the only one which he 
has found. Curiously enough, however, he employs the illus- 
tration from Fergusson's " Practical Surgery " a few pages 
before, in wliich a fracture of the coronoid process is seen, 
and which is taken from specimen 1 in King's College. The 
fragment would, no doubt, be drawn upwards and backwards 
by the temporal muscle, and might be felt in its new situa- 
tion, though this displacement would probably be limited 
by the very tough and tendinous fibres which are so closely 
connected with the bone, forming the insertion of the temporal 
muscle, and reaching down to the last molar tooth. Accord- 
ing to Sanson, fractures of the coronoid process do not admit 
of union, but Mr. Holmes (" Principles and Practice of 
Surgery") thinks that this statement is entirely un- 
supported, and that the idea that fracture of the coronoid 
process of the jaw does not unite by bone rests on no 
evidence. 

^ Considerable inflammation frequently follows a fracture of 
the jaw, even of a simple kind, particularly if it has been 
neglected or overlooked for some hours. The face becomes 
swollen, and the tissues beneath the chin infiltrated with 
serum, which is sometimes converted into pus, giving rise to 
troublesome abscesses. 



15 



CHAPTER II. 

COMPLICATIONS OF FRACTURE OF THE LOWER JAW. 

Wounds of the face are rare accompaniments of fracture of 
the lower jaw, except in cases of gunshot injury, and when 
found are usually the result of a kick from a horse. The 
wound itself requires treatment on ordinary principles, and 
is of little moment as regards the fracture (which is doubt- 
less "compound " also into the mouth), except as interfering 
with the aj)plication of the necessary retentive apparatus. 
In a case of extensive fracture of the lower jaw, the result 
of a kick from a horse, which I saw in the Westminster 
Hospital, under Mr. Holthouse's care, the lip and chin were 
extensively torn ; and in a case of Mr, Berkeley Hill's, in 
University College Hospital, the result of a fall, the wound 
beneath the chin very much interfered with the application 
of a modified form of Lonsdale's apparatus, which it was 
found necessary to employ. 

Hmmorrliage, beyond that resulting from laceration of the 
gums, is rarely met with, since, although theoretically one 
might imagine that the inferior dental artery would frequently 
be torn across, this appears not to be the case ; a result due, 
no doubt, to the fact that the elasticity of the artery allows 
of its stretching sufficiently to avoid rupture. In the Lancet 
of 12th October, 1867, a case of fractured jaw is reported, 
under the care of Mr. Maunder, in which severe haemorrhage 
into the mouth occurred through a fissure in the gum 
behind the last molar tooth. This was effectually controlled 
by digital compression of the carotid artery, which was main- 
tained for two hours and a half, after which no further 
bleeding occurred. Secondary haemorrhage has also been met 



16 COMPLICATIONS OF FRACrrURE OF LOWER JAW. 

with, for Steplien Smith, of Xew York, reports a case of 
double fracture iu whicli about a pint of blood was lost from 
the seat of fracture on the twentieth day. Injury of the 
soft parts about the jaws may give rise to severe haemorrhage, 
requiring prompt treatment ; thus Mr. Lawson has re- 
ported {Medical Times and Gazette, 1862,) a case iu which 
it became necessary to lay open the face iu order to secure 
the facial and transverse facial arteries, torn by the wheel 
of a cart, which liad fractured l)otli tlie upper and lower 
jaws. 

In the Appendix will l^e found a case (Case I.) of 
compound comminuted fractures of both upper and lower 
maxilhe, with extensive laceration of the face, in which 
tracheotomy became necessary, owing to the urgent dyspnaa 
supervening a few hours after the accident, due, probably, 
to blood becoming infiltrated into the tissues about the base 
of the tongue. A case of death during the administration 
of chloroform, which occurred at St. Bartholomew's Hospital 
in 1882, seems to have been due to injury of the larynx 
and extravasation of blood into the muscles of the root of 
the tongue, accompanying a fracture of the lower jaw caused 
by a blow in fighting. 

Dislocation and fracture of the tectli are not unfrequently 
met with, the former being the direct residt of a blow, or 
the consequence of the fracture running through the socket, 
and the latter the result of direct violence ; or, in the molar 
region particularly, in consequence of indirect force through 
the neighbouring teeth ; or from the teeth being forcibly 
driven against those of the upj)er jaw. (Tomes.) "VMiere 
the fracture had passed through the socket, the tooth may 
fall between the edges of the bone and prevent their proper 
coaptation, and this should be borne in mind when a tooth 
is missing and difficulty is experienced in setting a fi-acture, 
since Erichsen mentions a case where union was prevented 
until the tooth was removed. In the molar region the crown 
of the tooth may be broken off, one fang remaining in situ 
and the other dropping into the fracture, as was the case 
with the patient under my own care, from whom specimen 2 



PARALYSIS AND NEURALGIA. 17 

of the Kinsr's CoUeo-e Museum was taken. Teeth which 

O O 

are merely loosened, generally become reattached and useful, 
and should therefore not be removed. 

I am indebted to Mr. Margetson of Dewsbury for a case in 
which double fracture of the jaw occurred, with dislocation of 
several of the teeth, and fracture of the left second bicuspid, 
the crown of which was imbedded for more than two years 
in the tissues of the mouth, behind the incisor teeth. Mr. 
Margetson removed the crown from its abnormal position and 
also the fang ; and both, together with a plaster cast, showing 
very well the deformity resulting from the fracture of the jaw, 
are in the Museum of the College of Surgeons. (2123.) 

The front teeth may be broken off, with the portion of the 
alveolus containing them, by a horizontal fracture, either 
alone or in combination with a vertical fracture through the 
thickness of the bone. Specimen 1 of University College 
shows a vertical fracture through the symphysis, with a 
horizontal fracture running through the alveolus on the right 
side, separating the portion containing the right lateral 
incisor, the canine, and first bicuspid teeth. Such a frag- 
ment may be made to re-unite if treated at once, but when 
some days have elapsed, and the fragment is only attached 
by a portion of gum, removal must necessarily be performed. 
A case of the kind was recently under my own care, in the 
person of a man aged sixty, who had had a blow on the left 
side of the jaw six days before I saw him. I found a loose 
piece of alveolus three-quarters of an inch in length, and 
containing the left incisors and canine teeth, which was 
merely held by a portion of gum, there being no other 
injury to the jaw. The preparation is now in the Museum 
of the College of Surgeons. (879.) 

In fracture of the lower jaw in children — a very rare 
accident — when the fracture happens to involve the cavity in 
which a permanent tooth is being developed, exfoliation of 
the tooth, with a portion of the alveolus, is almost certain 
to ensue, as was noticed by Mr. Vasey in a case occurring 
in St. George's Hospital. 

Paralysis and Neuralgia from injury to the inferior dental 

C 



18 COMPLICATIONS OF FRACTURE OF LOWER JAW. 

nerve may be the immediate result of the accident, or be 
caused at a later period by some pressure arising from the 
development of callus. In by far the greater number of 
cases no injury of the nerves accrues, and this may be partly 
explained, as Boyer originally pointed out, by the fact that 
" the greater part of these fractures takes place between the 
symphysis and the foramen by which the nerve comes out." 

A case of paralysis of the inferior dental nerve, from a 
gunshot wound of the ramus, wdiich was under my care 
some years ago, will be subsequently referred to ; and 
Malgaigne describes a specimen, in the ]\Iusee Dupuytren, 
also the result of gunshot injury, in which the dental nerve 
was ruptured, and its canal obliterated at the seat of frac- 
ture. (See rig. 7.) 

Temporary paralysis of the inferior dental nerve must be 
of rare occurrence, since Malgaigne did not meet with it ; 
and Hamilton thinks that " the explanation may be found 
in the fact that the fragments seldom overlap to any apj)re- 
ciable extent, and that even the displacement in the direction 
of the diameters of the bone is generally inconsiderable, or, 
if it does exist, it is easily and promptly replaced." He 
thinks, moreover, that temporary anaesthesia of the chin 
might not improbably be overlooked at first, and would have 
ceased by the time the aj)paratus was removed. A. Berard 
saw a case of vertical fracture without displacement betw^een 
the second and third molar teeth, in which complete tempo- 
rary anaesthesia of the lip and chin as far as the median 
line existed {Gazette des Hujntmix, August 10th, 1841). A 
case of temporary paralysis of the dental nerve, from fracture, 
is mentioned also by Eobert {Gazette cles Hointaiux, 1859, 
p. 157), occurring in a woman, aged sixty-four, who was run 
over by a carriage, and who also suffered from fracture and 
displacement of the malar bone, with 'permanent ana3sthesia 
of the infra-orbital nerve. 

The cases of convulsions coincident with fracture of the 
jaw, recorded by Kossi and Flajani, would appear to have 
been due to injury of the brain, the result of the 
original accident and unconnected with the fracture, but it 



INJURY TO BASE OF SKULL. 19 

may happen that direct injury may be inflicted on the 
skull by the broken jaw. Thus Dr. Lefevre {Journal 
Hebdomadaire, 1834) gives the case of a sailor, aged twenty- 
two, who fell from a height upon his chin with the following 
result. There was almost complete inability to open 
the mouth, the jaws being tightly closed and the lower 
drawn backwards and a little to the left. There were 
tenderness and ecchymosis in the left temporo- maxillary 
region, and a little blood flowed from the left ear. The 
case was diagnosed to be one of fracture of the neck of 
the condyle. The man died six months after with brain 
symptoms, and on opening the head, the left glenoid cavity 
was found driven in, with a starred fracture of the tem- 
poral bone, between the fragments of which the condyle 
of the jaw was found. There was a large abscess in the 
brain. 

Similarly in the Museum of St. George's Hospital, there 
is a temporal bone with the unbroken condyle of the inferior 
maxilla driven through the glenoid cavity, producing a 
fracture of the middle fossa of the base of the skull in a case 
where there was an extensive comminuted fracture of the 
jaw itself, which, however, is not preserved. In contrast with 
this, may be mentioned another case which also occurred in 
St. George's Hospital, and the details of which will be found 
in the Appendix (Case II.), where the neck of the condyle and 
the base of the coronoid process having been broken through, 
the lower fragment was displaced and had produced laceration 
of the meatus auditorius externus, separating the cartilaginous 
from the osseous portion for nearly half its circumference. In 
this case considerable serous discharge flowed from the ear, 
leading to the suspicion of injury to the skull, but there were 
no brain symptoms, and the patient dying with delirium 
treinens, the skull, the membranes, and the brain were found 
perfectly healthy. 

In connexion with these cases may be mentioned those 
recorded by M. Morvan {Archives G4nercdes, 1856), who 
gives two cases of his own, and one by Montezzia, where a 
blow on the chin was followed by bleeding from the ear ; 

2 



20 COMPLTOATIONS OF FRA-CTCTRE OF LOWER JAW. 

and one case by Tessier, where a double fracture of the jaw 
from a kick by a horse was followed by bleeding from both 
ears. In all these instances the patients recovered. 

An instance of neuralgia, consequent upon old fracture of 
the lower jaw, occurred in St. Bartholomew's Hospital in 
1863. Mr. Wormald, under whose care the patient was, 
opened up the dental canal and excised a portion of the 
inferior dental nerve with the most satisfactory result. 
{Medical Times and Gazette, April 4th, 1863.) 

Abscess is not a very uncommon complication of severe 
injuries of the jaw, the matter pointing below the bone, and 
being in some cases probably as much the result of injudi- 
cious pressure by retentive apparatus as of the injury. A 
certain amount of pus commonly finds its way into the 
mouth through the lacerated gum in all cases of severe 
fracture, but the exit is usually sufficient to prevent the 
occurrence of abscess within the mouth. In neglected cases 
of fracture, the abscess may be connected with necrosis, and 
may open at some distance down the neck, and remain patent 
for many months ; thus I am indebted to Mr. Margetson, of 
Dewsbury, for a case where, in consequence of a neglected 
fracture (which from the twisting of the face to the left side 
would appear to have been one of the neck of the left 
condyle), three years after the receipt of the injury there 
was still a fistulous opening on the left side of the neck, 
about two inches below the angle of the jaw. 

Salivary fistula may result from a compound fracture of 
the lower jaw, or from an abscess burstmg externally in the 
case of a simple fracture. The treatment would of course 
be that for salivary fistula, arising from other causes, such 
as necrosis, &c. In the Appendix will be found a case 
(Case III.) occurring under the author's care, in wliich 
a salivary fistula was connected with necrosis and false 
joint in the ramus of the jaw, following a gunshot injury, 
and which was successfully closed. 

Necrosis to the extent of small portions of the alveolus 
not unfrequently follows fractm-e of the jaw, and without 
any permanent deformity occurring ; but when the necrosis 



NECROSIS AND ITS RESULTS. 



21 



affects the whole thickness of the bone, as may happen when 
the fracture is comminuted, and a portion becomes so 
detached as to lose its vitality, the consequent deformity may 
be very great. Of this a specimen in St. George's Hospital 




Museum (fig. 4) affords a good example, a loss of substance 
to the right of the symphysis having occurred, leading 
to the union of the halves of the bone at an acute ande. 



Fig. 5. 



Fig. 6. 





A still better example of the same kind of deformity, and 
from a similar cause, is seen in tig. 5, taken from a model 



22 COMPLICATIONS OF FRACTURE OF LOWER JAW. 

lent to me by Mr. Hepburn. The patient several years ago 
received a kick from a horse, which produced a compound 
comminuted fracture of the lower jaw. The central portion 
became necrosed and was removed by the late Mr. Aston 
Key, and appears to have extended from the second bicuspid 
tooth of the right side to the first molar on the left, the 
intervening teeth being wanting. The result, as seen in the 
model, is that the two halves of the jaw are united at an 
angle, of which the second bicuspid tooth forms the apex, 
the jaw being so much contracted that this tooth is tliree- 
quarters of an inch behind the upper incisor, as can be well 
seen in fig. 6. Here, by the skilful adaptation of artificial 
apparatus^ Mr. Hepburn has been enabled to restore the 
power of mastication and articulation^ which was previously 
much impaired, so that the patient (a clergyman) is able to 
perform his duties with satisfaction. 

A remarkable, and I imagine unique, case of necrosis and 
exfoliation of the two halves of the symphysis menti oc- 
curred to Mr. Henry Power, who has been good enough to 
give me the details of the case. Here the patient sus- 
tained a compound fracture of the symphysis by a severe 
fall, and some months after^ during the whole of wliich 
time profuse suppuration was going on in the part, two thin 
lamellae of bone, apparently the surfaces of the symphysis, 
came away, after which rapid solidification of the fracture 
ensued. 

Boyer, in his lectures, mentions having extracted from a 
fistula in the meatus auditorius externus, the necrosed 
condyle of a man who had had a fracture of the neck of the 
bone seven or eight months before. 

Dislocation. — I have been able to find, in the standard 
authors, the records of only two cases of fracture of the body 
of the jaw complicated by dislocation of the condyle from 
the glenoid cavity, and the accident must of necessity be a 
rare one, for the fact of fracture having occurred would 
tend to prevent the dislocation, since the leverage necessary 
would thus be interfered with. The cases in question are 
given by Malgaigne in his work on " Dislocations," one being 



DISLOCATION WITH FRACTURE. 23 

recorded by Delamotte, who saw a fracture of the body of 
the jaw with double dislocation, produced by the kick of a 
horse in a girl of between eleven and twelve years. The 
other was a more remarkable case, recorded by Robert, who 
saw a dislocation of the left condyle outwards, with fracture 
of the jaw in front of the right ramus, in a man who was 
knocked down on his left cheek, the wheel of a carriage 
passing over the right. 

A third case, however, is reported by Mr, Croker King 
{Duhlin Hospital Gazette, 1855), and occurred in a boy of 
eight, who suffered a fracture at the symphysis with dislo- 
cation of the left condyle upwards and backwards. There 
was bleeding from the ear, and the chin was much retracted 
and turned to the left ; the mouth was open, but could be 
closed, and it w^as then observed that the lower molars over- 
lapped the upper, but that the lower incisors were at least 
one inch hehind the upper. Reduction was easily effected, 
and the case did well. (Owing to an obscurity and apparent 
contradiction in the report, this case has been put down by 
Weber as an instance of unusual dislocation without fracture.) 

A fourth case of the kind is also briefly referred to by 
Mr. Gunning, of New York, in his paper on " Interdental 
Splints." {New York Medical Journal, 1866.) " The patient 
was thirty-six years old; the jaw was fractured through 
the symphysis and the right condyle dislocated outward and 
haekward, February 10th, 1866, in falling down stairs and 
striking the chin on a small desk.'" The dislocation was 
reduced before Mr. Gunning was called in. 

The case of fracture of the glenoid cavity by the dis- 
placed condyle in St. George's Hospital, already referred to, 
cannot be regarded as one of true dislocation. The treat- 
ment in these cases would of course be reduction of the 
dislocation before setting the fracture. 

In fractures of the neck of the jaw the condyle itself has 
been found displaced. Thus Holmes Coote (in his article on 
Injuries of the Face, Holmes' " System of Surgery," vol. ii.) 
mentions that Bonn, writing in 1783, gives an account of 
a case of the kind. There was a longitudinal fracture in the 



24 COMPLICATIONS OF FRACTURE OF LOWER JAW. 

middle of the bone, and at the same time the right condyle 
was broken off and dislocated forwards and inwards, lying 
united by callus near the foramen ovale. The pointed upper 
extremity of the neck of the lower jaw articulated with the 
glenoid cavity, and the separated head with the lateral part 
of the tubercle of the temporal bone. There was motion in 
the false joint. The same author mentions a case of fracture 
and dislocation of both condyles of the lower jaw, in a 
young man who had numerous injuries and lived five weeks. 
The condyles were found to be broken ofi', and fixed near 
the foramen on either side. 

Irregular Union. — Where the displacement of the frag- 
ments has been great, it may be impossible to keep them 
in proper position, and the result may be an irregular union 
of the bone, interfering more or less with its functions in 
after-life. This is particularly liable to occur in cases of 
double fracture, where the central portion of the jaw is 
much displaced by the muscles attached to it; and Mal- 
gaigne gives a drawing from a specimen of the kind in 
the Mus^e Dupuytren (fig, 7), in which the middle fragment 

Fig. 7. 




is displaced downwards and backwards, and has also under- 
gone such a change of position that its lower border is in- 
clined forward, and its anterior surface looks almost directly 
upwards, the union on one side being j)artly fibrous. 

An almost precisely similar state of things existed in a 
case of double fracture which came under ]Mi\ Bickersteth's 



NON-UNION AND FALSE JOINT. 25 

care, and wliicli will be found in detail under the head of 
" Treatment of Ununited Fracture," the central portion of 
the jaw having become much depressed, and united on one 
side, so that when the molars were in contact the incisor 
teeth were separated more than half an inch, the opposite 
fractm-e being still ununited. Here Mr. Bickersteth reme- 
died the deformity by sawing through the bone at the seat 
of the united fracture, and replacing the fragment in its 
proper position. 

The specimen of united fracture in University College 
Museum illustrates very well the effect of irregular union 
upon the teeth, and the masticatory power of the jaw. The 
fracture was in the right molar region, and appears to have 
led to the loss of all the teeth on that side except the last 
molar. The irregular union has resulted in a contraction 
of the alveolar arch, so that the left teeth have been thrown 
within those of the upper jaw, with the result of wearing 
away the opposed surfaces of the two sets — viz., the lower 
teeth on their outer and the upper on their inner surfaces. 
Hamilton expresses an opinion, "that time and the constant 
use of the lower jaw in mastication will gradually effect a 
marked improvement in the ability to bring the opposing 
teeth into contact." The specimen above referred to illus- 
trates the only mode in which such an improvement could, 
in my opinion, occur. 

The deformity resulting from loss of a portion of the 
bone near the symphysis, has been already referred to under 
the head of " Necrosis." Loss of substance in other parts 
of the jaw is apt to result in fibrous union or false joint, 
and this is especially the case in gunshot injuries. 

Non-union and False Joint. — Fractures of the lower jaw 
ordinarily unite with great rapidity and certainty, notwith- 
standing the difficulties often met with in maintaining perfect 
apposition of the fragments. Hamilton has noticed one 
instance, in an adult person, in which the bone was im- 
movable at the seat of fracture on the seventeenth day, and 
says that in no instance under his own observation has the 
bone refused finally to unite, although union lias been 



26 COMPLICATIONS OF FRACTURE OF LOWER JAW. 

delayed as long as eleven weeks. Cases of non-union and 
false joint have, however, been recorded and treated by 
Physick, Dupuytren, and others ; and a case has already 
been referred to which occurred under my own care, in 
which false joint followed a gunshot injury of the ramus of 
the jaw. (See Appendix, Case III.) The liability of the 
lower jaw to false joint, as compared with other bones, may 
be gathered from a table of 150 cases drawn up by Norris 
(American Journal of Medical Sciences, January, 1842). Of 
these 150 cases 48 occurred in the femur, 48 in the humerus, 
33 in the leg, 19 in the forearm, and two iu the lower 
jaw. 

Non-union may be simply the result of neglect of treat- 
ment, and union may take place readily as soon as the parts 
are placed under favourable circumstance. Thus a patient 
was under Mr. Wormald's care who, five weeks before ad- 
mission into St. Bartholomew's Hospital, had fractured his 
jaw between the canine and bicuspid teeth on the left side, 
for which he had not been treated. There was some little 
necrosis, and sinuses had already formed beneath the cliin; but 
under appropriate treatment the bone thoroughly united in 
five weeks. {Medical Times and Gazette, Jan. 17, 1863.) 
And yet, on the other hand, fracture of the jaw has no 
doubt been occasionally untreated, and still has united. 
Thus Boyer saw consolidation occur, though not without 
deformity, in a water-carrier who would not endure any 
dressing, nor abstain from eitlier sjoeakiug or chewing when 
the pain did not prevent him. Notwithstanding the most 
careful treatment, however, the jaw may fail to unite if the 
case has been complicated in any way. Thus Mr. Berkeley 
Hill mentions a case {British Med. Journcd, March 2, 1867) 
of double fracture, where great difficulty was experienced in 
adapting suitable apparatus, and where one fracture united 
perfectly, but the other remained miunited. And again, 
on the other hand, over-solicitous attention appears occa- 
sionally to interfere with union ; for A. Berard relates the 
singular case of a child whose fracture made no progress 
towards recovery till the apparatus, an ordinary bandage, 
was removed ; and Mr. Hill's case, mentioned above, illus- 



UNUNITED FRACTURE. 27 

trates the same point, for he informs me that the second 
fracture became consolidated without any treatment. 

The occurrence of necrosis at the point of fracture is the 
most probable cause of non-union, and a small amount of 
this may prevent, or at least delay, the union taking place, 
as in Mr. Power's case, where two thin lamellte exfoliated 
from the symphysis ; and, moreover, callus is not thrown 
out so copiously for the repair of fractures of the jaw as 
it is in the long bones. Gunshot injuries seem especially 
liable to produce ununited fractures of the lower jaw, 
probably by inducing necrosis ; and of this an example 
under the author's care has been already alluded to. On 
this subject the late Dr. "Williamson, of Fort Pitt, has 
made the following observations in his work on " Military 
Surgery," p. 22: — 

" Ununited fracture of the lower jaw does not seem to 
have been of such frequent occurrence amongst the wounded 
from the Crimea as those from India. Six were admitted 
from India with fracture of the lower jaw. Of these three 
were invalided, two sent to duty, and one to modified duty. 
Of these six cases, three were instances where the fracture 
remained still ununited, though the ends of the bone were in 
contact. In one case the ball struck one side of the lower 
jaw, and was cut out on the opposite side one month after, 
fracturing the bone on both sides. In one, the ball was 
cut out from below the tongue. In one case, from a shell 
wound, there was a double fracture, one on the right side 
of the ramus, and also another near the symphysis, with 
great laceration of soft parts, and resulting deformity ; the 
first-named fracture remained ununited. In another case 
there was a double fracture from a musket-ball ; the frac- 
ture at the entrance of the ball still remains ununited ; 
that at the exit has become united. In one case, from 
round shot, the whole of the left ramus of the lower jaw 
had been extracted at tlie time, or came away by exfolia- 
tion, leaving a large chasm and great deformity on this side 
of the cheek from laceration of the soft parts. In one case 
there was a fracture on the left side, at the angle of the 
jaw, still ununited. 



28 COMPLICATIONS OF FRACTURE OF LOWER JAW. 

" Attempts were made to excite action in the ends of the 
bone by forcibly rubbing together, and afterwards keeping 
the two fracture ends at rest by wire round the teeth, and 
a piece of cork placed between the teeth of the posterior 
fragment and that of the upper jaw, but without success. 
It was not thought advisable to try the effects of a seton 
or other means of inducing the effusion of new bone." 

Piokitansky, in his " Pathological Anatomy" (Sydenham 
Society's Translation, iii. p. 216), describes the unnatural 
joints resulting from fracture as of two kinds ; " one more 
or less resembling a synarthrosis, the other like a diar- 
throsis, and accordingly, in its proper sense, a new joint. 
In the former case, the fractured ends of the bone are held 
together by a Ligamentous tissue. Either a disc of ligament 
the thickness of which may vary, is interposed between 
them, and allows of but little movement, or, as occurs 
when there has been loss of substance either from injury, 
absorption of the fractured ends, or otherwise, ligamentous 
bands connect the fragments, and allow them to move freely 
on each other. The connecting tissue appears to be nothing 
more than the intermediate substance, which has failed to 
become transformed into the secondary callus and remains 
in its first state. 

In the second case, a ligamentous articular capsule is 
formed, and is lined by a smooth membrane which secretes 
synovia. The fractured surfaces adapt themselves to each 
other and become covered with a layer of tissue which is 
fibro-ligamentous, or more or less fibro-cartilaginous, or 
which resembles and sometimes (Howship) really is carti- 
lage. They may articulate immediately with one another, 
or may have between them an intervening layer of ligament 
which corresponds to an interarticular cartilage ; and their 
movement upon each other is more or less free, according 
to the size of the articular capsule and the form of the 
articulating surfaces. These last are sometimes horizontal, 
(plane ?) and smooth ; they glide over each other, and allow 
of restricted motion ; sometimes one surface becomes convex 
and the other concave ; sometimes both are rounded off. 



FIBROUS UNION OF FRACTURE. 



29 



and lying within a capacious articular capsule far apart, 
they come in contact only during particular movements. 
The articulating capsule is the product of the inflammation 
of the soft parts ; the cartilaginiform layer which covers the 
ends of the bone is secondary callus arrested in its meta- 
morphosis and converted into a fibroid tissue. The other 
ligamentous cords which are sometimes present, and the 
structures resembling an interarticular cartilage, are rem- 
nants of the intermediate substance. Both forms of new 
joint, but more particularly the synarthrodial form, have an 
analogue in the lateral new joints sometimes formed be- 
tween the masses of callus thrown out around two adjoining 
fractured bones." 

The only museum specimen of ununited fracture of the 
lower jaw I have met with is in University College (fig. 8), and 

Fig. 8. 




belongs to Eokitansky's first division, since it is a good ex- 
ample of fibrous union filling the interval between the right 
canine tooth and the ramus of the jaw, there having evidently 
been considerable loss of bony substance at the seat of frac- 
ture. A very similar specimen is, I am informed, in the 
Museum of the Eoyal College of Surgeons of Edinburgli, 
the fibrous tissue extending from the symphysis to the left 



30 COMPLICATIONS OF FRACTUEE OF LOWER JAW. 

bicuspid teeth. I have no doubt, however, that the other 
form, the true false joint, does occur in the loM-er jaw both 
as the result of violence (and particularly in the ramus of 
the jaw) and as the result of operative interference, having 
had the opportunity of watching the formation of a false 
joint in two cases in which I performed Esmarch's opera- 
tion for closure of the jaws, which will be referred to in 
another part of this essay. 

The amount of inconvenience which the patient expe- 
riences from an ununited fracture of the jaw will vary ac- 
cording to the position of the false joint. In the ramus it 
appears to give very little, if any, inconvenience, the new 
joint performing the function of the temporo-maxillary arti- 
culation ; and the same may be said, according to my expe- 
rience, of the false joints pm-posely made for the relief of 
closure of the jaws, although in the body of the bone, since 
the portion of the jaws posterior to the joint is immovably 
fixed by the cicatrices. When, however, a false joint occurs 
in the body of an otherwise natural bone great inconvenience 
results, the patient being unable to masticate properly ; and 
his health is apt to suffer, as was the case with Dr. Physick's 
patient, who was successfully treated by the use of the seton 
eighteen months after the accident. Here the fracture, ori- 
ginally double, united on the right side, but the left, which 
was broken obliquely, remained ununited. {Philadelphia 
Journal of Med. and Phijs. Sciences, vol. v. p. 116.) A case 
is related also by Horeau {Journal de Medecine, par Corvi- 
sartj X. p. 195), which shows the inconveniences experienced. 
A colonel received a gunshot wound which broke the right 
side of the body of the jaw some lines from its junction with 
the ramus, resulting in a false joint between the first and 
second molar teeth. In the ordinary condition of things 
these two teeth were on the same level, and they were not 
deranged even by pushing the fragments fi-om behind for- 
ward or from before backward. But if the posterior frag- 
ment was raised and the anterior depressed, the second molar 
tooth was several lines above the level of the first. The re- 
sult was great difficulty in chewing on the injured side, and 



UNUNITED FRACTURE. 



31 



consequently the food was habitually carried to the left 
molar teeth, and its trituration was neither easy nor com- 
plete. Tlie digestion became impaired, and the patient 
suffered from pain after food, &c. I have recently seen a 
gentleman whom I attended some years ago with Mr. 
Moger, of Highgate, and who had received most serious 
injuries of the face from the pole of a waggon. In this 
case the patient barely escaped witli his life, owing to ery- 
sipelas and great constitutional disturbance. There was 
double fracture with extensive necrosis of the lower jaw, 
which has resulted in a false-joint on the right side ; but for 
this the patient has declined all treatment, whether surgical 
or mechanical, and though he is quite incapacitated for 
mastication, he is well nourished by means of food passed 
through a mincing-machine. 

A remarkable case of ununited fracture in the mental 
region, the result of gunshot injury in the Crimea, is 
recorded by the late Mr. Cox Smith, of Chatham {Dental 
Review, 1858-9), and was satisfactorily treated mechanically 
by that gentleman. The condition of the parts was briefly 
as follows : — The symphysis with the incisors, right 
canine, and one bicuspid tooth, having been carried away, 
the jaw was divided into two unequal portions, which 
fell together when at rest ; but upon opening the mouth 
Fig. 9. Fig. 10. 




the left only was fully acted upon by the muscles and 
the right rode over it, as shown in tlie illustration 



32 COMPLICATIONS OF FRACTURE OF LOWER JAW. 

(fig. 9). Much pain was caused by any attempt to separate 
the two fragments so as to make them correspond to the 
teeth of the uj)per jaw ; hence mastication was impossible, 
articulation was much interfered with, and the patient could 
only sleep on liis back, since lying on either side caused dis- 
placement of the corresponding section of the jaw. Fig. 10 
shows the model first taken by Mr. Smith, and its resemblance 
to cases of united fracture with loss of substance in the incisor 
region previously described, will be at once noticed. The 
treatment of this interesting case will be referred to under 
another section. 

The case of ununited fracture successfully treated by 
Dupuytren was also the result of a gunshot injury, and the 
following was the condition of the parts when the patient 
came imder that surgeon's care, fom' years after the receipt 
of the injury (Dupuytren's Lcgons Orales, vol. iv.). The ball 
had struck the right side of the jaw just in front of the 
masseter, and had carried away a portion of the bone at the 
junction of the body with the ramus. The posterior frag- 
ment, which contained the wisdom tooth, was twisted so that 
the tooth looked towards the tongue, and at the same time 
M'as dra^vn outwards into the cheek. The anterior fragment 
formed by the remainder of the bone was displaced so that 
its fractured end was carried to the right side and below the 
other, an interval of an inch intervening, corresponding to 
the first and second molar teeth Avhich had been carried 
away. The riding of the fragments was so great that the 
second bicuspid tooth was in contact with the wisdom tooth, 
when the parts were left to themselves ; but, when traction 
was made, a S2:)ace of an inch was produced between them. 
Of course therefore the teeth of the two jaws did not 
correspond, and there was consequently great difficulty of 
mastication, which was increased by the want of power in 
the jaw itself. If unsupported by a bandage the jaw dropped, 
the mouth remained open and saliva dribbled out, the chin 
beins carried over to the ri"ht side. 



33 



CHAPTER III. 



TUEATMEXT OF FRACTURED LOWER JAW. 



The treatment of fractured lower jaw after tlie reduction 
of any displacement^ the occasional difficulties of which have 
been alluded to in a previous section, is usually of a simple 
character ; but cases sometimes arise in which the most 
carefully adapted mechanical contrivances fail to effect a 
good union. The apparatus employed for the maintenance 
of the fractured portions in apposition may be conveniently 
divided into two classes, external and internal to the mouth, 
though it may be necessary to combine the two methods in 
a few instances. 

The simplest form of external apparatus consists of the 

Fig. 11. 




ordinary four-tailed bandage or sling, with a slit for the chin 
to rest in (fig. 11). This is made of a piece of bandage 



34 TREATMENT OF FRACTURED LOWER JAW. 

about a yard long and three inches wide, which should have 
a slit four inches long cut in the centre of it, parallel to 
and an inch from the edge. The ends of the bandage should 
then be split to within a couple of inches of the slit, thus 
forming a four-tailed bandage with a hole in the middle. 
The central slit can be readily adapted to the chin, the 
narrow portion going in front of the lower lip, and the 
broader beneath the jaw ; and the two tails corresponding 
to the lower part of the bandage are then to be carried over 
the top of the head, while the others are crossed over them 
and tied round the nape of the neck. The ends of the 
two bandages may then be knotted together, as seen in the 
illustration. 

A single roller may be employed to support the jaw, as 
recommended by the American surgeons C4ibson and Barton ; 
but this is more difficult of application, and is more apt to 
become disarranged. 

Combined with the sling, a well padded splint of either 
pasteboard or gutta-percha may be often advantageously 
employed. The material which is selected being cut long 
enough to pass w^ell up to the sides of the jaw, is to be divided 
at the ends, so as to resemble the four-tailed bandage (fig. 12). 
Beinc; tlien softened in warm water it can be lined with lint 
or some soft material and adapted to the jaw, the chin rest- 
ing on its centre, and the sides being doubled around and 
beneath the Ijone, as in fig. 13. 

Fift. 12. Fig. U. 




C 





Hamilton states that he has frequently noticed the ten- 
dency of the sling, as ordinarily constructed, to carry the 
anterior fragment backwards, especially when there is a double 
fracture. He has devised a special form of apparatus (fig. 14) 



Hamilton's sling. 35 

for which he claims the following ; — " The advantage of this 
dressing over any which I have yet seen consists in its 
capability to lift the anterior fragment vertically ; and, at 

Fig. 14. 




the same time, it is in no danger of falling forwards and 
downwards upon the forehead. If, as in the case of most 
other dressings, the occipital stay had its attachment oppo- 
site to the chin, its effect would be to draw the central 
fragment backwards. By using a firm piece of leather as a 
maxillary band and attaching the occipital stay above the 
ears, this difficulty is completely obviated." 

Ligature of the teeth with silk or wire is a method 
which has frequently been employed for the treatment of 
fractured jaw, but is unsatisfactory, from the loosening of 
the teeth and irritation of the gums which are apt to be 
produced. AVhen employed, care should be taken to select, 
if possible, perfectly sound teeth around which to apply 
the ligature, which should be prevented from sinking down 
to the neck of the tooth so as to cut the gum. An 
astringent wash should be frequently employed during the 
treatment to maintain the healthy firmness of the gums 
themselves. 

D 2 



36 



TREATMENT OF FRACTURED LOWER JAW. 



A more satisfactory apparatus is tlie wire-splint devised 
by Mr. Hammond, L.D.S., of Leinster Square, who has 
kindly supplied the following details of the method of apply- 
ing it. 

To make the Hammond Wire-splint. — After bringing the 
broken parts into apposition, tie them temporarily together 
with silk passed outside the second tooth on each side of 
the line of fracture. 

With a suitable "tray" and very soft wax, take an 
impression of the mouth (whicli need not be deeper than the 
teeth), supporting the chin while doing so with tlie left hand. 

Fig. 15. 




Make a model of this in plaster of Paris in the usual way. 
If there has been any displacement of the parts, saw down 
between the teeth corresponding to the fracture, adjust the 
several pieces to the proper " bite," and fix in position. 

Now take a length of iron wire (stout hair-pin size) and 
carefully make a frame to fit round the teeth, soldering the 
ends to<?ether with silver solder. Cut several five-inch 



THE HAMMOND WIRE-SPLINT. 



37 



lengths of fine soft iron binding wire — both ends of which 
should be cut to points, which will greatly facilitate the 
passing of them through the tartar between the teeth. Should 
there be much tartar a line " broach" may be necessary. 

To cqyply the Splint. — Place the patient upright in a high- 
backed chair, and rinse the mouth. Slip the frame over 
the teeth, holding it gently in place with the left hand, and 

Fig. 16. 




with the right hand take one of the pointed wires and pass 
it between the first and second molars on the left side, 
directing it slightly downwards so that the end will come 
out under the inner bar of the frame. Have the forefinger 
of the left hand inside to feel for the point, and with it turn 
the wire upwards and outwards so as to avoid wounding the 
tongue. Then bring this wire back, as shown in fig. 16, 
i.e., over the inner bar of the frame, and under the outer ; 
cross the ends and turn them aside — repeat this on the 
right side of the mouth, Wben all the ligatures are passed, 
seize the ends of the first wire with a small pair of pliers, 
and twist them on each other nearly tight, doing the same 



38 TREATMENT OF FRACTURED LOWER JAW. 

on the left side, and when the pressure is equalized cut off 
the wires about half an inch from the frame, as at B. Now 
twist all the ligatures quite tight, and tuck them away under 
the frame, as at C. The jaw will now he found perfectly 
firm, and the patient able to bite steadily on it without 
pain. 

It will be found after a few days tliat the ligatures will 
require twisting a little tighter (owing to the movement of 
the teeth in their sockets), this can easily be done if care 
be taken to follow the directions given, and never on any 
account to put one wire round more than one tooth. The 
attempted employment of one long wire for all the teeth by 
some operators has very injuriously afiected the reputation of 
this splint for firmness and solidity, by virtue of which 
qualities good results can always be obtained. 

Dissimilar metals must not be used in the construction of 
the frame and wires, owing to the galvanic action set up 
and unpleasant taste produced, not to mention the irritation 
to the teeth. 

Suture of the jaw itself has been employed from time 
to time for the treatment of both recent and old fracture, 
and to insure the union of the two halves of the bone after 
its division for removal of the tongue by Syme's method. 
Dr. Kinloch of Charleston treated, in 1858, a case of com- 
pound oblique fracture of unusual form, which has been 
already referred to (p. 9), by this method, after other means 
had failed. " A semi-lunar incision, about two inches long, 
was made upon the side of the face^ the middle of the inci- 
sion reaching under tlie base of the jaw. With Brainard's 
smallest-sized drill a perforation was made through each 
fragment, the drill being entered on the outside, close to 
the base of the bone, and about one-eighth of an inch from 
the rough extremity of each fragment, and made to traverse 
the bony tissue and the mucous membrane covering it 
within the buccal cavity. The drill was afterwards thrust 
between the fragments and turned about, so as to slightly 
lacerate the intermediate connecting tissue. A stout silver 
wire was tlien passed tlnougli tlie perforations in the bone. 



THOMAS S WIRE- SUTURE. 



39 



from without inwards through the posterior fragment, and 
in the contrary direction through the. anterior one ; and 
their ends were tightly twisted together, so as to bring the 
fragment into secure apposition. 

" By the 26th of September good consolidation was 
effected, and the suture, which had occasioned but little 
suppuration, was nntwisted and removed. On the 15th of 
October the patient left the hospital, with the fistulous 
opening healed and a good use of the jaw." — American 
Journal of Medical Sciences, July 1859. 

Mr. Hugh Thomas of Liverpool has recently advocated 
the use of the wire-suture in the treatment of recent frac- 
tures, and two of his illustrative cases, which had most 
satisfactory results, will be found in the Lancet, January 




19th, 1867. This method has been more fully elucidated in 
a pamphlet, and consists either in drilling the fragments and 
passing a copper wire, each end of which is then coiled upon 
a "key " formed by a steel rod with a slit in it (fig. 17); or, 
in cases where the teeth are sound, in passing a loop of wire 
around the teeth on each side of the fracture, and then 
twisting it up with the key (fig. 18). The advantage of this 
method is that the wire can be tightened from time to time, 
as may be required during the treatment, without liability 
to breakage. I have employed it in a case of division of the 



40 



TREATMENT OF FRACTUKED LOWER JAW. 



jaw for removal of tlie tongue, witli advantage ; and my 
friend Mr. Eushtou, Parker of Liverpool speaks highly of 



Fig. 18. 




the method as " the most simple and effectual yet devised." 
One of Mr. Parker's cases will be found in the Appendix 
(Case lY.). 

In the Lancet, August 17th, 1867, Mr. Wheelliouse 
of Leeds has recommended the following plan, w-hich 
has proved successful in a case of triple fracture (fig. 19), 
but which presents no great advantage over the ordinary 
wire : — 

" Two silver pins were made with Hat, circular, and per- 
forated heads, each pin being about an inch and a quarter 
in length. Two holes W"ere bored with an Archimedian 
drill through the substance of the jaw-bone — one between 
the roots of the outer incisor and canine teeth of tlie un- 
broken side, and the second between tlie roots of the same 
teeth of the fractured side. Through these holes the two 
pins were passed from hchind forwards, the perforated heads 
threaded with a good stout silk ligature, resting upon the 
Hoor of the mouth under cover of the fra^num of the tongue. 
Having been well thrust forward through the drill-holes, 
the points were bent in opposite directions, the loose frag- 
ment was placed in good position, tlie ligature was brought 



wheelhouse's method. 41 

forward over the teeth, and a figure-of-8 suture was then 
made round the reversed ends of the pins." 

Fig. 19. 




/ 
According to Malgaigne, Guillaume de Salicet advised 
not merely to tie the adjacent teeth together, but to fasten 
them to those of the upper jaw. The necessity for such a 
contrivance must be very rare, but Dr. Fountain success- 
fully treated a case of double fracture and fracture of the 
left condyle, which has been already referred to (page 13), 
by a somewhat similar method. " Holes were drilled 
through a front incisor of each jaw, and a double strand 
of fine annealed jeweller's iron wire was passed through 
and twisted so as to keep the parts in exact apposition, the 
central fracture, which gave no trouble, being supported by 
a pasteboard splint. In ten days the wires gave way, and 
a cord was inserted composed of four of the same wires ; and 
in this way the jaw was held securely and innnovably until 
all the fractures were united — viz., four weeks, during which 
time the patient was nourished by liquids, whicli were easily 



42 TREATMENT OF FRACTURED LOWER JAW. 

drawn into the nioiith through the teeth. Perfect union, 
without a particle of deformity, took place, and now, nearly 
four years after, no one would be able to tell that any frac- 
ture had ever taken place. — New Yorh Journal of Medicine, 
January, 1860. 

The simplest form of apparatus within the mouth consists 
of wedges of cork, about an inch and a half long and a 
quarter of an inch in thickness at the base, but sloping 
away to a point, as recommended by Boyer and Miller. 
These may be placed between the molar teeth, and, if they 
can be kept in position, will maintain the regularity of 
the teeth and keep the incisors separated for the introduction 
of food, a four-tailed bandage being applied externally. My 
own exj)erience is that the corks cannot be maintained in 
position, and after a few hours roll about in the mouth ; and 
this I find also to have been the experience of other sm-- 
geonS; including Sir "William Fergusson, with whom also I 
fully agree, that the majority of cases do well with merely 
the simple bandage, not very tightly applied. 

Wedges of gutta-percha, introduced warm into the mouth, 
so as to become moulded to the teeth and gums, are higldy 
recommended by Hamilton, both as supports and, in some 
degree, as lateral splints for the fracture. ]\Iutter's clamp, 
consisting merely of a plate of silver, folded over the tops 
and sides of two or more teeth adjacent to the fracture, is a 
contrivance which, in its original form, can have been but of 
little service, but as modified by ]\Ir. Tomes and others is a 
very efficient method of treating fractures of the body of the 
jaw. The modification consists in making the silver cap 
fit accurately to tlie teeth, for some distance on each side 
of the fracture, by moulding it to a plaster cast of the jaw\ 
The cap is then lined Avith gutta-i)ercha, which, being warmed 
when the apparatus is applied, fills up interstices and fixes 
the cap, the fragments being maintained in position wliilst 
the a]iplication is being made. Although the assistance of 
a dentist would be required for the proper preparation of 
the cap, it may not be out of place to notice the best method 
of obtaining a satisfactory model upon which the caji is to 



METAL CAPS FOR THE TEETH. 43 

be formed, for which I am indebted to Mr. Tomes. When 
the displacement of the fragments is great (as is invariably 
the case where siicli apparatus is required), it is best to take 
a cast of the jaw in wax, without attempting to bring the 
fragments into proper relation. Into this the plaster is 
poured, and, when set, a fac-simile of the displaced fracture 
is of course produced. By now sawing out the piece of 
plaster between the extremities of the fragments, these can 
be brought together, and a model of the perfect jaw will be 
produced, upon which the metal can be carefully fitted. When 
all is prepared, by carefully adjusting the fracture, tlie cap 
will of necessity fit and will maintain the fracture in its 
normal position. 

Mr. Howard Hayward lias been very successful in treating 
cases of fracture of the jaw, of both recent and old date, by 
silver caps, fitted accurately to the teeth on each side of the 
fracture, and also over the gum to the depth of half an 




inch in front and a (puirter of an inch behind them (fig. "20.) 
To the upper surface of the lAnte two pieces of stout curved 
wire are soldered, so as to turn round the angles of the 
moutli without touching them, and these are attached to a 
simple gutta-percha splint, moulded externally to the jaw, 
and retained in position by an ordinary four-tailed bandage. 
Holes drilled in the metal cap, opposite the point of fracture, 
permit of the exit of any discharge, but this is usually insig- 
nificant in quantity when the fracture is once properly set. 
Mr. Hayward prefers metal to vulcanite or gutta-percha for 
the cap, on account of its small bulk, and the consequent 
small interference with the natural closure of the mouth — a 
point of some importance, on account of the retention of the 
saliva. 



44 TREATMENT UF FRACTURED LOWER JAW. 

]\Ir, Barrett, dental-surgeon to the London Hospital, has 
kindly shown me models of cases in which he has obtained 
most satisfactory results, by both metal and vulcanite inter- 
dental splints, secured in the mouth by small screws passing 
between the necks of the teeth. One of his cases was in a 
child, and here the delicate temporary teeth suffered no 
da ma ire from the screws. 

Mr. Gunning, of New York {Ncvj York Medical Journal, 
and British Journal of Dental Science, 18C6), has contrived a 
form of interdental splint^ composed of the vulcanite- rubber 

Fig. 21. 




now in common use among dentists, which has yielded very 
satisfactory results in his hands, and of which the following 
is a condensed description. 

Fig. 21 represents the inner surface of a splint which 
incloses all the teeth and part of the gum of the lower jaw, 
and merely rests against the upper teeth when the jaws are 
closed. This splint is adapted to the treatment of all cases 
which have teeth on both sides of the fracture, except those 
with obstinate vertical displacement. The holes marked A 
go through the top of the splint, for the purpose of syringing 
the parts within with warm water during treatment. The 
dark round spots in all the cuts represent holes for similar 
purposes. 

Mr. Gunning has generally used this splint without any 
fastenings, but in children, or even adults, it is sometimes 
advisable to secure it by packthread wire screws passing 
into or between the teeth, or by the wings and band of fig. 24. 

In cases witli obstinate vertical disi)lacement, the splint. 



gunning's interdental splints. 45 

in addition to fitting the teeth and gum of the lower jaw, 
must also inclose the upper teeth, as shown in fig. 23, 

Fig. 22. 




•c 



where screws may he seen opposite both the lower and 
upper teeth. 

By this arrangement the fragments of the lower jaw are 
secured, not only relatively to each other, but also to the 
upper jaw. B, is a triangular opening, of which one side 
corresponds to the cutting edge of the lateral incisor, 
which stood in the end of the fragment most displaced before 
the splint was applied, C, an opening for food, speech, &c. 
D, a channel for the saliva from the parotid gland to enter 
the mouth, its fellow being seen on the other side of the 
splint. E', a screw opposite the lower canine tooth, the head 
of the fellow screw being just discernible. E, the head of 
a screw opposite the upper first molar tooth, the end of its 
fellow being seen on the other side. 

Fig. 23 shows the wings for cases having no tcdh in cither 
jaw — the ends of the wings within the mouth being imbedded 
in a vulcanite splint similar in principle to that of Fig. 22. 
F, upper wing. G, lower wing. H, mental band to hold 
the jaw up to the splint. I, neck strap to keep the band 
back. K, balance strap to hold the cap in place. 

Wings made of steel may be quite light. They should 
have fine teeth along the edges where the bands and tapes 
bear to prevent slipping, and small holes every half-inch to 
hold the strings, lacing, &c. The arch of the wings should 



46 TREATMENT OF FRACTUEEl^ L(nVEK JAW. 

1)6 liigli enough to give the lower lip room to go well up. 
Tlie wings for each side of the jaw are in one piece, and the 

Fig. 23. 



parts within the mouth pass back in the line of the upper 
gum. They are thinned down and pierced with holes, that 
the ruljhcr in wliich tlu^y are imbedded may hold them 
firmly. 

The tape strings pass from the cap inside and under the 
upper wings, then up between them and the tape lacings 
(tig. 23) which keep the strings from slipping, to the cap 
whence they started. The mental band passes up between 
the sides of the lower jaw and the wings, where it is tied by 
the strings, which pass through the holes. The band is 
cut oft' to show this ; but when worn it should be turned 
down on the outside and pinned just below the wings. The 
neck strap should be sewed to the mental band on one side 
and pinned on the other, and worn tight enough to keep the 
band from slipping forward over the chin. 

The jaw and splint are supported by the cap in front of 
its centre. This is coimterbalanced by the elastic strap 
which passes from the back of the cap down around a non- 
elastic, and much heavier, strap, extending across and 
fastened to the shoulders by elastic ends. The balance 
strap returns to the cap, and is buckled tight enough to hold 
the jaw up. At night it may be slackened to do this with 



gunning's interdental splints. 47 

the neck flexed. It slides on the shoukler strap as tlie head 
inclines to either side. 

In order to meet the case of practitioners out of reach 
of a dentist, Mr. Cliinning has suggested a splint made of 
tin and lined with gutta-percha (fig. 24) very mucli resem- 
bling Mr. Hayward's metal cap. Six or eight sizes are to 

Fig. 24. 




be cast and kept ready for use, from which one could be 
selected suitable for the jaw. The wings are of malleable 
iron, tinned to prevent rusting and for more readily solder- 
ing. Three sizes would probably be sufficient to select from. 

The splint .should have a handle in front that it may be 
used as a cup to take the impression of the jaw — the holes 
])eing useful to allow a small probe to be pressed through 
the wax down to the teeth, thus allowing air to enter to 
facilitate the removal of the impression, and when in use as 
a splint giving entrance to warm water, thrown from a 
syringe, to keep the parts clean. 

The splint should he made to fit well by l^ending, cutting 
off the edges and rounding them smoothly. When a 
tooth projects so as to keep the splint from fitting, a hole 
may be cut to let the tooth through, if the metal cannot be 
hammered out. This should all be done before taking the 
impression, as a well-fitted cup assists greatly in this im- 
portant matter. 

(The adaptability of this splint is shown in the fact that 
the one from which the cut was taken had been used sue- 



48 TREATMENT OF FRACTURED LOWER JAW. 

cessfully on two different jaws, so unlike that the first was 
a quarter of an inch wider, where the ends of the splints 
rested, than the second. When fitting it to the second jaw, 
it was necessary to cut off a part of the right wing, to keep 
it clear of the corner of the mouth. This accounts for the 
difference in the width of the arches as seen in the cut. 
The indentations ou the top of the splints were made by 
the boys in eating.) 

One of Mr. Gunning's successful cases was particularly 
interesting from the important political position of the 
patient, no less than the serious nature of the injuries, 
received at the hands of a would-be assassin. 

Mr. J. B. Bean of Atlanta, Georgia, appears to have 
employed a vulcanite interdental splint very similar to Mr. 

Fia. 25. 




Gunning's, but with the addition of a mental compress, with 
great success among the wounded soldiers of the Confederate 
army, and his apparatus is very favourably reported upon by 
Inspector-General Covey. {RicJimond Medical Journal, and 
British Journal of Dental Science, 1866.) Hamilton also 
speaks well of the apparatus in the fourth edition of his 
work on " Fractures," and gives an illustration, from which 
the accompanying drawing (fig. 25) is taken. 



bean's apparatus. 49 

Ur. Covey writes : — " The adjustment of the splint to the 
fracture is very simple. It is inserted into the mouth of 
the patient ; the fragments drawn forward, and the teeth 
adjusted to their corresponding indentations. The jaws are 
then closed and held firmly in position by the application 
of the mental compress and occipito-frontal bandage ; this 
prevents any displacement of the splint or motion of the 
jaws. 

The mental compress is designed for retaining the teeth 
in their indentations of the splint, by uj)ward pressure ap- 
plied to the base of the mental process, counteracting thus 
the traction of those muscles which most tend to cause dis- 
placement. There is an advantage also in relieving the 
parts from the lateral pressure produced by the four-tailed 
bandage or double-cross roller bandage, generally applied 
to these cases. 

The compress is composed of a light piece of wood, 
which is four and a half inches in length, three-sixteenths 
of an inch in thickness, and one inch and a half in width 
in the middle, tapering to seven-eighths of an inch, and 
round at the ends ; to each of which is attached a metallic 
side-piece four or five inches in length, and from three- 
quarters to one inch in width ; also a shallow cup fitting 
the apex of the chin. Encasing these side pieces are the 
temporal straps made of stout cloth, and secured by a strong 
cord at the base of each piece. 

The occipito-frontal bandage is composed of a band pass- 
ing around the head, from the forehead to the occipital 
protuberance behind, and secured by a buckle one inch to 
the right of the median line behind ; of another strap 
secured to the band in front and behind ; and a third strap 
extending from the temporal buckles on either side, and 
secured to the middle strap at the point of crossing." 

A combination of external and internal splints was invented 
by Eutenick, a German surgeon, in 1799, and improved by 
Kluge. It is thus described by Dr. Chester {Medico-Chirnrgical 
Beview, vol. xx. p. 471) : — " It consists, 1st, of small silver 
grooves, varying in size according as they are to be placed 

E 



50 TREATMENT OF FIIACTURED LOWER JAW. 

on the incisors or molars, and long enough to extend over 
the crowns of four teeth ; 2nd, of a small piece of board, 
adapted to the lower surface of the jaw, and in shape re- 
sembling a horse-shoe, having at each horn two holes, one 
on either side ; 3rd, of steel hooks of various sizes, each 
having at one extremity an arch for *the reception of the 
lower lip, and another, smaller, for securing it over the silver 
channels on the teeth, and at the other end a screw to pass 
through the horse-shoe splint, and to be secured to it by a 
nut and a horizontal branch at its lower surface ; 4th, of a 
cap or silk nightcap to remain on the head ; and 5th, 
of a compress corresponding in shape and size with the 
splint. The net or cap having been placed on the head and 
the two straps fastened to it on each side, one immediately 
in front of the ear and the other about three inches farther 
back, which are to retain the sjDlint in its position by pass- 
ing through the two holes in each horn ; a silver channel is 
placed on the four teeth nearest to the fracture, on this the 
small arch of the hook is placed, and the screw end having 
been passed through a hole in the splint^ is screwed firmly 
to it by a nut, after a compress has been placed between 
the splint and the integuments below the jaw. If there 
is a double fracture, two channels and two hooks must of 
course be used." 

Bush invented a similar apparatus in 1822, and Houzelot 
in 1826 ; since which the apparatus has been variously 
modified by Jousset, Lonsdale, Malgaigne, and perhaps 
others. 

Lonsdale's apparatus, as Mr. Berkeley Hill remarks 
{British Medical Journal, March 2, 1867), " is only suited 
to cases of fracture between the incisors, as its ivory cap is 
too short to reach far along the arch of the teeth. It is 
also very cumbrous ; and causes great pain by the pressure 
under the chin necessary to keep the fragment in place, and 
by the jogging of the vertical part against the sternum." 

Fig. 26 shows this ajDparatus somewhat modified by 
Mr Hill, to whom I am indebted for the illustrations. In 
the ordinary Lonsdale's apparatus, the rod carrying the 



Lonsdale's apparatus. 



51 



ivory cap (a) for the incisors slides freely up and down a 
bar projecting downwards from the chin-piece (b), and, 
when in the required position, is fixed by a pin. Mr, Hill 
has had a screw thread cut on the bar, on which a nut (e) 



Fig. 26. 




travels so as to force down the rod carrying the cap (a), 
and thereby approximate the cap on the incisors to the 
chin-piece. 

When this apparatus is to be applied, the fragments are 
placed in position by the hands, the ivory cap set on the 
incisors, and the chin-piece, which should be well padded 
with lint or wool stitched in wash-leather, brought up into 
place under the jaw, and the two made fast. Tlie two cheek- 
pieces are then adjusted so as to press lightly on the jaw at 
each side, to prevent the apparatus from swaying aside out 
of place ; and a tape is fastened to a hole at each end of the 
horse-shoe, and carried behind the neck, to keep the instru- 
ment from slipping forwards. So applied, Lonsdale's apj^a- 
ratus permits opening of the mouth for eating and speaking; 
and, if the fracture be single and between the incisors, it 
keeps the fragments in position very fairly. 

Fig. 27 represents the modification of Lonsdale's splint, 
contrived by Mr. Berkeley Hill, for the treatment of a com- 
plicated case of double fracture in University College Hos- 

E 2 



52 TREATMENT OF FRACTURED LOWER JAW. 

pital in 1866, the ivory cap of the incisors being replaced 
by a metal mould of the alveolar arch, and the lateral pads 
removed. 

Fig. 27. 




Mr. Moon, of Guy's Hospital, has devised another modifi- 
cation of Lonsdale's splint, which has the advantage of being 
made in two halves (fig. 28 B B.) so as to fit any jaw exter- 



FiG. 28. 




Fig. 29. 




nally. The metal cap for the teeth (fig. 29) is kept in place 
by horizontal bars passing at the angles of the mouth, or may 
be iised separately by being secured with wires. 

The great difficulty in using all forms of rigid splints to the 



TREATMENT OF UNUNITED FRACTURE. 53 

jaw is the tendency of the support for the chin to produce 
abscess and ulceration by pressing upon the sharp border of 
the bone ; and the cases in which a simple metallic interdental 
splint would not effect a cure must be rare. 

The treatment of fracture of the neck of the lower jaw, in 
those rare cases where the patient survives the injury and 
the nature of the accident is recognised, is sufficiently simple 
when there is no displacement, since the ordinary bandage 
will in most cases suffice. When, however, the condyle is 
displaced by the action of the pterygoideus externus^ reduc- 
tion must be effected as recommended by Eibes, by drawing 
the jaw horizontally forwards, and at the same time pushing 
the condyle outwards with the finger introduced far back 
into the mouth. Eeduction being accomplished, the jaw 
must be pressed upwards and backwards to fix the condyle 
in the glenoid cavity, after which a bandage may be applied. 

Gross says the best means to counteract the tendency of 
the external pterygoid to produce displacement is " to confine 
a thick graduated compress behind the angle of the bone, 
the treatment being in other respects the same as in fracture 
of the body of the jaw." (Gross's " Surgery," p. 967). 

TJie Treatment of Ununited Fracture of the Jaiv. — The 
causes of non-union of a fractured jaw have been described 
in a previous section. When the delay is due to a superficial 
necrosis, time for exfoliation to take place is all that is re- 
quired ; when, however, the necrosis is extensive, or the loss 
of substance great, it is not desirable to produce union 
between the fragments, since thereby an unsightly deformity 
will be induced, which can be avoided by the use of apparatus 
to retain the parts in their normal relation. This subject 
will be referred to more particularly under the head of 
" Gunshot Injuries." 

Dupuytren, in 1818, treated a case of ununited fracture, 
the result of a gunshot injury, in the person of a Eussian 
officer {vide p. 32), three years after the receipt of the injury, 
by resecting the extremity of one fragment and rasping the 
other. In order to maintain the fragments in position the 
dentist Lemaire was called in, and devised the following 



54 TREATMENT OF FRACTURED LOWER JAW. 

plan, the fracture being on the right side of the jaw : — 
" First, to carry the posterior fragment inward, he united 
by means of a platinum wire tlie wisdom tooth in this frag- 
ment to one of the bicus23ids of tiie other side ; then, to 
carry the anterior fragment forward and lessen the over- 
lapping as much as possible, a second wire was stretched 
from the first lower bicuspid on the right side to the first 
upper bicuspid on the left ; and a third bound together the 
two canine teeth on the left side." ( Vide Malgaigne, and 
for the entire case Dupuytren's Zegons Oralcs, vol. iv.) A 
cure was accomplished at the end of two months, but one 
of the wires had nearly bisected the tongue ; and as it had 
gradually become embedded the flesh had closed over it, and 
it had to be cut and withdrawn. 

Dr. Physick in 1822 treated a case, two years after the 
receipt of the injury, by the introduction of a seton between 
the ends of the bones. This was left in situ for three 
months, and induced suppuration and the discharge of frag- 
ments of necrosed bone, with an ultimate cure. (Fhila- 
delphia Journal of 3Iedical and Physical Sciences, vol. v. 
p. 116.) 

Suture of the fragments of bone would appear to offer 
the readiest means for keeping the two portions in appo- 
sition, and this plan has been successfully carried into exe- 
cution by Mr. Bickersteth, of Liverpool, Avho, in his paper 
read before the Medico- Chirurgical Society in 1864, nar- 
rated two cases in which he had succeeded in producing 
union by fastening the two fragments together by means of 
a drill, or some similar contrivance. 

The first case was a fracture of the lower jaw, in which 
the bones had united in such a position as to render the 
patient a most unsightly object. As the incision that would 
have been necessary in this instance for the purpose both 
of putting the bone into proper position and removing 
deformity of the soft parts, would not have allowed the use 
of external splints or su2:)ports ; and as it was found imprac- 
ticable to effect this object by fixing the teeth by an aj^pli- 
ance within the mouth, it was absolutely necessary that 



TEEATMENT OF UNUNITED FRACTURE. 55 

some means should be devised by which the divided portions 
of the jaw conki be securely fixed. It occurred to Mr. 
Bickersteth that pegs or nails would answer the purpose, 
especially as he had already observed their presence caused 
so little inconvenience. Accordingly, at the operation the 
apposition of the fractured portions was secured by means 
of two round-headed nails. They most effectually answered 
their purpose, and no external splint or bandage was re- 
quired. The case did well, no undue action being set up. 
On the twenty-second day after the operation one of the 
nails came away. The patient left the infirmary perfectly 
well, the jaw being firmly united in its proper position, and 
the deformity of the soft parts removed. One of the nails 
remained in, and the last accounts state that its presence 
caused no iiiconvenience. The second case recorded was 
one that presented many points in common with the one just 
narrated. No external incision was made, and ordinary 
drill-heads were substituted for nails. The result was every- 
thing that the operator could have wished. 

Dr. Cooper, of San Francisco, treated successfully an un- 
united fracture of the lower jaw by silver sutures. In the 
report of the case the exact seat of the fracture is not given, 
but it was evidently in the body of the bone. The peri- 
osteum was dissected up, the ends of the bone bared, after 
which they were carefully united, and the case did well. 
{Fhiladdiihia Medical and Siivfjical Eeportcr, 1862, and 
Medical Circular, July 23, 1862.) 



5G 



CHAPTER IV. 

FKACTUIIE OF THE UPPEK JAW. 

Fkactures of the upper jaw are not nearly so common as 
those of the lower^ though their results are often more 
serious, owing to the great violence necessarily undergone. 
As in the lower jaw, fractures of the alveolus may result 
from the extraction of teeth, and particularly from the use 
of the " key ;" and so well ascertained was this fact, that 
in former days even, when the key was recommended and 
employed extensively, Mr. Thomas Bell (" On the Teeth/' 
p. 301) proscribed its use in extracting the upper wisdom 
teeth on account of the danger of producing fracture of the 
tuberosity of the maxilla, against which the fulcrum would 
rest. A fracture thus produced may extend to the palatine 
process, and even to the palate bone, and might, if extensive, 
give rise to necrosis and subsequent exfoliation of large 
portions of bone. 

Eractui-es of the upper jaw may be produced indirectly 
by falls on the face ; thusListon (" Practical Sm-gery," p. 55) 
narrates the case of a man who, slipping on a slide in the 
street^ fell and struck the malar bone of the left side ; he 
had sustained a vertical fracture through the orbitar process 
of the superior maxilla. 

Direct blows upon the bone itself are, however, the most 
frequent causes of fracture, and these, from the nature of the 
injury, are often compound. 

Mr. James Salter has recorded a case {Lancet, June 16, 
1860) of a young gentleman who sustained fracture of the 
upper jaw from violent contact with a fellow-cricketer's 
forehead. Here fortunately none of the incisor teeth were 
knocked out, as so frequently happens in accidents of the 



FRACTURE OF THE UPPER JAW. 



57 



kind ; but a fracture of the bone was produced immediately 
behind the right canine tooth, which extended backwards so 



Fig. 30. 




Drawing from tlie plaster cast of the upper jaw, inve rte J. 
Fig. .31. 




Illustration ot the gold plate or splint ; a, b, and c corresponding to 
the first and second pre-molars and first molar respectively. 

as to inchide the alveoli of the bicuspids and first molar 
teeth, which were driven inwards towards the median line, 
to the extent of about one-third of an inch, as seen in the 
drawing (fig. 30). There was a corresponding depression on 
the outer side of the jaw, and this was somewhat apparent 
also on the face. Very little swelling followed the injury, 
and there was not much pain except on manipulation. The 
principal inconvenience was due to the want of proper 
apposition of the teeth of the two jaws, and the mouth con- 
sequently could not be closed satisfactorily. On endeavour- 



58 FRACTURE OF TUE UPPER JAW. 

ing to force the displaced bone into its proper situation, 
considerable pain was produced ; it could not be completely 
reduced, and resumed its former position as soon as pressure 
was withdrawn. Distinct crepitus was felt during this 
manipulation. 

Mr. Salter succeeded in overcoming the tendency of the 
fragments to displacement by the adaptation of a gold plate 
(fig. 31) to it and to the adjacent teeth, and a complete cure 
was the result. 

Tlie kick of a horse often inflicts most serious injuries 
upon the upper jaw^ and of this the classical case recorded 
by Itichard "Wiseman, in his " Chirurgical Treatise" (1794), 
is a good example. Here a boy, eight years old, received such 
a blow on the middle of his face, that he appeared at first 
dead, and afterwards lay in a prolonged coma. " Wlien I 
first saw him," says Wiseman, " he presented a strange 
aspect, having his face driven in, liis lower jaw projecting 
forward ; I knew not where to find any purchase, or how 
to make any extension. But after a time he became sensible, 
and was persuaded to open liis mouth. I saw then that the 
bones of the palate were driven so far back that it was im- 
possible to pass my finger beliind them, as I had intended, 
and the extension could be made in no other way. I ex- 
temporized an instrument, curved at its extremity, which I 
engaged behind the palate, and having carried it a little 
upward used it to draw the bone forw\^rd, which I did with- 
out any difficulty ; but I had hardly withdrawn the instru- 
ment when the fractured portions went back again. I 
then contented myself with dressing the face with an astrin- 
gent cerate to prevent the afflux of the humours ; I likewise 
prescribed bleeding ; and some hours afterwards I had an 
instrument better constructed to reduce the large mass of 
displaced bone to its proper position. I had it held by the 
child's hand, by that of its mother, or of an assistant, each 
for a certain time. Kothing else was done. Thus by our 
united attention the tonicity of the parts was maintained ; 
the callus was developed, and in proportion as it became 
solidified the parts became stronger, the face assumed a good 



INJURY TO FACIAL BONES. 59 

appearance, certainly better than could have been hoped for 
after such marked displacement, and the child was entirely 
cured." 

The most frightful injury to the face (except from gun- 
shot wounds) I ever witnessed, was from the passage of a 
waggon wheel over the face of a man who fell in the street. 
Here the bones were completely shattered, and the maxilla3 
were torn from one another, and death was instantaneous. 
A cast of this frightful deformity is in the museum of the 
Westminster Hospital. 

A case very nearly as desperate at first, but which fortu- 
nately recovered, was admitted into the same hospital in 
1860, and resulted from the overturn of a cab upon the face 
of its fare, who at the moment was leaning out of window 
to direct the driver. Here, in addition to a fracture of the 
lower jaw a little to the left of the median line, there were 
two fractures of the superior maxilla, about an inch on 
either side of the median line ; the nasal bones were broken; 
both malar bones were loose and separated from their at- 
tachments, and the left bone was fractured, as also the 
external angular process of the frontal bone. Though not 
positively ascertained, the vomer was no doubt fractured, 
and jDrobably the vertical plate of the ethmoid too. In Dr. 
Fyfe's report of the case {Lancet, July 18, 1860), which I 
can confirm by personal observation, it is well noticed, — " It 
was remarkable to observe how movable the bones of the 
face were. On watching the patient's profile whilst he was 
in the act of swallowing food, the whole of the bones of the 
face were observed to move up and down upon the fixed part 
of the skull as the different parts were brought into motion ; 
it appeared as if the integuments only retained them in their 
position. It was a curious feature in the case that notwith- 
standing the very extensive injury done, and the violent 
character of the force which caused them, not a single tooth 
was fractured or misplaced." This patient made a perfect 
recovery, and his treatment will be alluded to under another 
section. 

Fracture of the upper jaw extending into the antrum may 



60 FRACTURE OF THE UPPER JAW. 

give rise to subsequent suppuration in that cavity, as 
remarked by Liston, but this is by no means a necessary 
cousecpience. A remarkable case of transverse fracture of 
the upper jaw which communicated with the nose and with 
both antra was recently under Mv. Hutchinson's care in the 
London Hospital, in which perfect recovery took place with- 
out exfoliation of any part of the bone, although the alveolus 
containing all the teeth was completely separated and 
depressed about half an inch. Here the injury was the 
result of a " jam" between a " lift" and a cross bar. 
{Medical Circular, February, 1867.) A very similar case 
occurred to Dr. Guentha, when a workman was struck in the 
face by the angle of a large mass of stone. Here there was 
complete separation of the alveolar process of the ujiper jav/, 
the entire arch in an unbroken state lying on the lower jaw, 
only suspended by some shreds of the gum and soft palate. 
This man also made a perfect recovery. {British and Foreign 
Quarterly Rcvieiu, October, 1860.) In the summer of 1871 
two patients were admitted into University College Hospital 
within a few hours of each other, in both of whom the superior 
maxilhe were fractured and freely movable. In one case 
perfect recovery ensued, and death in the other, the post- 
mortem examination proving that there was no injury to the 
base of the skull. 

In cases such as these, when there is obvious displace- 
ment there can be no difficulty in the diagnosis of the 
fracture, but cases have no doubt frequently occurred where 
a fracture without displacement has been overlooked. Dr. 
A. Guerin has elaborately investigated this subject {Archives 
Gdndrcdes dc Medceine, July, 1866), and has shown from a 
preparation taken from a fatal case and from experiments 
upon the dead body, that violent blows below the orbits 
fracture not only the maxillary bones, but that the fracture 
usually extends to the vertical portion of the palate bone 
and the pterygoid process of the sphenoid, without producing 
tlie slightest displacement. Tlie diagnosis of the injury 
cannot be established by any external manipulation, but by 
carrying the linger into the mouth and pressing against the 



COMPLICATIONS OF FRACTURE. 6 

internal pterygoid plate, pain will be produced and mobility 
of the process will be ascertained. The diagnosis was con- 
firmed in one of Dr. Guerin's cases which recovered, by an 
ecchymosis beneath the mucous membrane of the palate. In 
his fatal case he found fracture of the vertical plate of the 
ethmoid, in addition to the other injuries. 

The nasal process of the superior maxilla has been frac- 
tured by blows which have also driven in the nasal bone, 
and in these cases emphysema of the cellular tissue of the 
face is not uncommon, and is best checked by the application 
of collodion. A complication of this form of fracture which 
has been met with, is permanent obstruction of the nasal duct, 
leading to subsequent troublesome epiphora, of which I have 
seen an instance. 

Separation of the two maxilla? in the median suture has 
been seen in cases of fatal injury to the face, &c., on many 
occasions, but Malgaigne gives a case of the kind where the 
patient recovered. The patient, a man aged twenty-one, 
owing to a fall from a height sustained, in addition to other 
injuries, "a separation of the upper maxillary and palate 
bones in their median suture to the extent of nine milli- 
metres, with depression of the entire left side of the face 
without any alteration of the soft parts." The parts came 
together spontaneously, and the patient recovered without 
deformity. 

Hamilton, how^ever, quotes (p. 102) a case from Harris, 
of New York, in which a child, two years of age, had separa- 
tion of the maxillary and palate bones in the median line, 
the separation being sufficient to admit the little finger, and 
here the bones were still open six weeks after the accident. 

Complications. — The teeth of the upper jaw may be broken 
or dislocated, as in the case of fracture of the lower jaw ; 
but if merely loosened, should never be removed, since 
they will probably become again firmly attached. 

Splintering of the bone is much more common in the 
upper than the lower jaw, particularly after gunshot in- 
juries, and here modern experience has shown the advisa- 
bility of leaving the fragments to become consolidated, as 



62 FRACTURE OF THE UPPER JAW. 

they almost invariably do, and the non-necessity for the 
performance of dangerous operations of resection of the 
fragments — a subject which will be again referred to. 

Htemorrhage is much more frequent and copious in frac- 
tures of the upper than in those of the lower jaw, as might 
be anticipated from the greater vascularity of the part. A 
case of fracture of both upper and lower jaws, where pro- 
fuse hsemoiThage was caused by division of the facial artery, 
has been already referred to, but tlie liaBmorrhage not un- 
frequently comes from the internal maxillary vessel and may 
be immediately fatal. Secondary hiemorrhage in case of 
severe injury to the upper jaw is by no means uncommon, 
and accorchng to the Surgeon-General of the American 
Army (Circular No. 6, Washington, Xovember 1, 1865,) was 
the principal source of fatality in these cases, ligature of the 
carotid artery having been frequently performed with the 
result of only postponing for a time the fatal event. 

Nervous Affections. — Injury to the infra-orbital nerve 
and its branches must necessarily ensue in cases of severe 
fracture and comminution of the superior maxilla, and con- 
sequent numbness or modification of sensation will be the 
result. A lady, recently under my care, who fell do^vn a 
flight of stairs and sustained severe injuries to the head and 
face, although no fracture of the jaw could be detected, 
suffers from partial anaesthesia and a pricking sensation in 
the skin below the orbit. Eobert mentions {Gazette des 
Hopitaux, 1859, p. 157) the case of a woman who was run 
over and sustained a fracture with permanent paralysis of 
the infra-orbital nerve. Serious brain symptoms may ensue 
when the fracture runs back to the sphenoid bone as de- 
scribed by M. Guerin (p. 60), since the fissure may extend 
to the cranium, and this is especially likely to happen when 
the whole of the septum narium is driven back with the 
jaws. 

Treatment of Fractiire of the Vyim- Jaw. — Fractures of 
the upper jaw require but little treatment compared with 
those of the lower jaw, since the part is naturally so much 
more fixed that there is little difficulty in keeping the frag- 



TflEATMENr OK FKACTURE OF UPPER JAW. G3 

ments in position. The haemorrhage, which is often free, 
must be arrested by cokl, the application of ^styptics, and, as 
a last resource, the actual cautery. The operation of deli- 
gation of the carotid artery in these cases has yielded such 
unsatisfactory results as to render the surgeon unwilling to 
resort to it except under the most desperate circumstances, 
and he would in my opinion be justified in laying open the 
face and removing large fragments of bone so as to apply 
the cautery more satisfactorily, rather than resort to a dan- 
gerous and doubtful operation. When, as is most commonly 
the case, the soft tissues of the face are lacerated and the 
haemorrhage arises from them, the bleeding vessels must be 
secured with ligatures in the ordinary manner. 

All authorities are agreed as to the non-advisability of 
removing the fragments of a broken upper jaw, since, owing 
to the vascularity of the part, they almost invariably unite 
readily. Malgaigne says, " In common fractures of the 
upper jaw there is one principle which surgeons cannot too 
carefully bear in mind — that is, that all splinters, however 
slightly adherent, should be scrupulously preserved, as they 
become reunited with wonderful facility. This remark was 
made by Saviard ; Larrey has strongly insisted on it, and we 
have seen that M. Baudens, who so much urges the extrac- 
tion of splinters, has likewise made a s^Decial exception of 
these cases." (Packard's translation, p. 304.) Hamilton 
remarks that the experience of American surgeons during the 
war confirms these observations. " Owing to the extreme 
vascularity of the bones composing the upper jaw, the frag- 
ments have been found to unite after the most severe o'un- 
shot injuries with surprising rapidity, the amount of necrosis 
and caries being usually inconsiderable compared with the 
amount of comminution" (p. 106). 

Notwithstanding this, however, Hamilton gives a lengthy 
account of a case of fracture of the upper jaw, in wliich he, 
in conjunction with Dr. Potter, thought it necessary to 
remove a fragment which included the floor of the antrum 
and had been drawn down and displaced in an attempt to 
extract a loose tooth. " The time occupied in this operation 



64 FRACTUIIE OF THE UPPER JAW. 

was at least one hour, during which we were every moment 
in the most painful apprehension lest we should reach and 
wound the internal carotid artery, which lay in such close 
juxtaposition to the knife that we could distinctly feel its 
pulsation. After its removal the haanorrhage was for an 
hour or more quite profuse, and could only be restrained by 
sponge compresses pressed firmly back into the mouth and 
antrum" (p. 103). Such dangerous operations are much to 
be deprecated, and cases already quoted prove that even after 
greater separation the bone will thoroughly reunite. 

Mention has been made of the difficulty Wiseman ex- 
perienced in reducing the fragments to their proper position 
in his case, and the means he adopted to overcome it. In 
the majority of cases the finger introduced into the mouth 
and passed around the alveoli will readily restore any irre- 
gularity, being aided; if necessary, by the introduction of a 
strong elevator or pair of dressing forceps into the nostril. 
The teeth in adjacent fragments may be advantageously 
wired together to keep them in position, or, where there is 
great comminution and irregularity of the alveoli^ a piece of 
soft gutta-percha may be adapted to them so as to hold and 
support the fragments. The lower teeth should not be 
allowed to come in contact with this until it is thoroughly 
hardened, or they would become imbedded and thus cause 
its displacement. In very complicated cases, as in examples 
of fractures of both jaws, the vulcanite interdental splints 
of Mr. Gunning (described under Fractures of the Lower 
Jaw) might be employed, these having an aperture for the 
introduction of food. 

Graefe employed an apparatus, of which the following 
description is giv.en by Malgaigne (Packard's translation, 
p. 301). " A curved steel spring, properly padded, is applied 
over the forehead, and kept in place by a strap buckled 
around the occiput. This steel has at each side a hole with 
a screw for making pressure ; and a steel brace to which it 
affords a j^oint d'apj^ui, for acting steadily on the dental 
arch. Now these braces, descending to the level of the free 
edge of the upper lip, curve backward so as to go around 



graefe's apparatus. G5 

the lip without wounding it ; getting thus at the dental 
arch, they again curve so as to apply themselves to it. But 
as the pressure of the braces should have the effect of keep- 
ing the detached teeth in proper relation with the rest, a 
silver trough duly padded is made to fit over both to a suffi- 
cient length ; and upon this trough the braces exert their 
pressure. It is easy to see how, by altering their height as 
regards the spring over the forehead, the pressure may be 
regulated to the right degree." 

A somewhat similar apparatus, but with the addition of 
a pad which can be applied externally so as to support the 
cheek, was brought before the Surgical Society of Paris, in 
September, 1862, by M. Goffres. 

In the rare cases of separation of the maxilhie, a spring 
passing behind tlie head and making pressure upon the 
maxilhe after the manner of Hainsby's hare-lip apparatus, 
might be advantageously employed. 



66 



CHAPTEE V. 

GUXSHOT INJURIES OF THE JAWS. 

Gunshot injuries of the jaws have necessarily been inci- 
dentally referred to in considering fractures of those bones 
separately, but it ^vill be convenient to class the injuries of 
the two maxillae by fire-arms together, since these accidents 
affect both bones in the majority of cases. Laceration of 
the soft tissues and consequent hemorrhage are almost con- 
stant accompaniments of wounds of the face, and the mortality 
attending them is liigh, both from the immediate effects of 
the injury, and from the frequent occurrence of secondary 
haemorrhage. The. effects of the modern arms of precision 
contrast unfavourably in this respect with those of the 
round bullet of the old fire-lock, for though the latter fre- 
quently lodged in one of the ca^dties of the face for an in- 
definite time, the irregular mass of metal driven 'with tre- 
mendous velocity by the modern rifle commits greater havoc, 
splintering the bones and lacerating the soft tissues most 
extensively. 

The Surgeon- General of the American army reported in 
Xovember, 1865 (Circular No. 6, Washington), that from 
the commencement of the war to October, 1864, of 4167 
wounds of the face reported to him, there were 1579 frac- 
tures of the facial bones ; and of these 891 recovered and 
171 died — the terminations being still to be ascertained in 
517 cases. Secondary haemorrhage was the principal cause 
of mortality in these cases, and the carotid had frequently 
been tied with the result of postponing for a time the 
fatal result. 

The Crimean returns from the 1st of April, 1855^ to the 



CRIMEAN EXPERIENCE OF GUNSHOT WOUNDS. 67 

end of the war, show 533 wounds of the face, of which the 
bones were injured in 107 instances. 445 patients returned 
to duty, 74 were invalided, and 14 died. 

Of 21 cases of wounds of the face with injury to tlie 
bones from the Indian Mutiny reported by Dr. Williamson, 
six were examples of fracture of tlie lower jaw, ami of these 
three remained ununited. 

The following extract is from the otticial '^ Medical and 
Surgical History of the British Army in tlie Crimea," vol. 
ii. p. 305, and illustrates the experience of that war, Mdiich 
has been largely confirmed by that of the later American 
war : — " Wounds of the face, though presenting often a 
frightful amount of deformity, are not generally of so 
serious a nature as their first appearance miglit lead the 
uninitiated to expect. The reason of this, apart from tlie 
fact that the face contains no vital orgaii, seems obviously 
to be the very free supply of blood which this part receives. 
From tliis cause the flesliy structures readily heal, and even 
the bones are so supplied that extensive necrosis rarely 
happens. The bone tissues, also, are softer than the long 
bones of the extremities, and we therefore but seldom here 
meet with long fissures and extensive necrosis as a result 
of concussion of bone, so often seen in them. This leads us 
to tlie very important practical inference, not in this situa- 
tion, as a rule, to remove bony fragments, unless the com- 
minution be great, or the fragment completely detached 
from the soft parts. Even partially detached teeth will often 
be found not to have lost their vitality, and, if carefully re- 
adjusted, will become useful. There is indeed no great 
object beyond, perhaps, the present comfort of the patient 
to be attained in removing either fragments of bone or 
loosened teeth in the great majority of instances. If they 
die, they become loose, and are readily lifted away without 
trouble to the surgeon, and but little pain to the patient. 
This observation is especially applicable to fractures of the 
lower jaw. Surgeons in this war have seen so many cases 
of badly-fractured instances of this kind unite, and that 
with a very small amount of deformity, that men of cx- 

F 2 



08 GUNSHOT INJURIES OF THE JAWS. 

perieuce are uow excessively cliaiy of removing any portion 
of this Lone, unless it has become dead, or the fragment is 
so situated as to interfere considerably ^vith the adjustment 
of the remainder, or the bone so much comminuted as to 
give no probable hope of its becoming consolidated, or so 
sharply angular as to threaten further injury to the soft 
parts, or to interfere materially with their adjustment and 
retention in situ. In these fractures of the lower jaw, 
much less support and adjustment than we are in the habit 
of tliinkiug advantageous in ordinary cases of fracture of it, 
will frequently be found necessary, or even admissible. A 
complicated apparatus cannot be borne at hrst, on account 
of the condition of the soft parts, and the application of 
slight support by a gutta-percha or Startin's wire splint, and 
a split bandage, is all that can be done. Any attempt at 
ligaturing the teeth is very generally not only useless, but 
injurious, and it is surprising how the parts often as it were 
adjust themselves, with but little aid from the surgeon. 
One interesting case may be mentioned wdiere the wdiole 
of the bone, from angle to angle, was so comminuted 
by gunshot that no choice was left but to remove the 
fragments. The injury to the soft parts was very con- 
siderable, and one difficulty, occasioned by the loss of all 
support in front — viz., the tendency of the tongue to fall 
backwards and close the opening of the glottis, well illus- 
trated. The man, llOwe^'er^ generally remedied this himself 
with his fingers, and nothing was done, or required to be 
done, on this account beyond carefully watching him. He 
naturally, as it were, adoj)ted a position on his side, resting 
mainly on his forehead, so as to have the face as much in 
the prone posture as possible, and thus the weight of the 
organ assisted in keeping it in position." 

Gunshot wounds of the upper jaw through the mouth 
are usually of suicidal origin, and of this a specimen, pre- 
sented by myself, is now in the Museum of the College 
of Surgeons (832), being the skull of a man who fired a 
pistol into his mouth. The red lines on the preparation 
mark the outline of tlie fracture, and it will be seen that a 



FRACTURE OF THE LOWER JAW. 69 

great part of the hard palate was driven in, and that the 
bullet, after fracturing extensively the base of the skull, 
carried away a considerable portion of the vault of the cra- 
nium. The malar bone, with the outer wall of the antrum, 
is broken off on the right side, and the malar bone on the 
left is separated from the maxilla at the articulation. In a 
second case of the kind, whiclr I also had the opportunity of 
examining immediately after death, the injuries were similar 
in extent. 

In the preparation referred to there is an oblique fracture 
of the lower jaw on the left side, running backwards through 
the socket of the first molar tooth, and an oblique crack has 
been produced on the inner surface of the right side of the 
bone, in an exactly corresi:)onding position. Fracture of the 
jaw had occurred also in the second case alluded to, and has 
been frequently noticed under similar circumstances, the 
fracture depending upon the concussion of the explosion 
and the rapid development of gas within tlie mouth. This 
is not without exception, however, since, in tlie University 
College Museum, there is the skull of a man who fired a 
pistol into his mouth, in wliich the palate is extensively 
damaged, but the lower jaw perfect. When the bullet 
actually enters the mouth the injury is usually immediately 
fatal, but Otto Weber has recorded (Handhwh dcr Allgc- 
meinen U7ul Spcciellen Chirurgie, Part III. 1866) a case of 
recovery : — " The patient, through despair arising from 
pecuniary embarrassments, determined to shoot himself in 
the churchyard. He held the pistol before his open mouth, 
and, after firing, fell senseless to the ground. After some 
time he came to himself, looked for his spectacles, which had 
fallen off his face, and made the gravedigger bring him to 
me. The palatal vault was simply perforated, and the ball, 
completely flattened, was sticking in the body of the sphenoid 
bone, where it could be felt by the index finger introduced 
into the hole by which it had entered. After some fruitless 
attempts to extract it, it fell into the patient's throat and lie 
spat it out. Subsequently the hole in the palate completely 
closed up again, and the patient recovered both physically 



70 GUNSHOT INJURIES OF THE JAWS. 

and iiioially." In this case the lower jaw does not appear 
to ]\a\c suiTered, but JMr. Barrett has shown me the model 
of a case in which a pistol bullet, fired at the open mouth, 
glanced off an incisor tooth, and ran up the side of the face, 
emerging near the malar bone, and where nevertheless the 
lower jaw was broken by the explosion. 

I was once called in by Dr. Whitmarsh, of Hounslow, 
to see a patient who had fired a pistol, loaded with small 
shot, into liis mouth, smashing the palate and fracturing 
the lower jaw in two places by the explosion, but who 
eventually made a good recovery ; and in the Lancet, Nov. 7, 
1868, will be found a remarkable case under the care of 
Mr. Sydney Jones, of recovery, after a similar injury, com- 
plicated by division of one optic nerve and injury to the 
brain. 

Because a bullet has entered the mouth, and infiicted 
injury upon the bones of the palate, &c., it does not neces- 
sarily lodge there ; thus, in the " Medical and Surgical 
History of the Crimea," is the case of John Collins, 97th 
Eegiment, wdio was wounded on the 8th Septemlier and sent 
to hospital on the 14th, having been struck by a musket-ball, 
which had entered the mouth slightly cutting the upper lip, 
and had comminuted the palate plate of the superior maxilla, 
and appeared to be lodged somewhere among the ethmoid 
cells. There was but little constitutional disturbance. All 
the incisor teeth of the upper jaw became dead and had to 
1)6 removed, as well as some fragments of the palate plate, 
but the wound slowly healed and finally filled u]), leaving 
tlie man but little the worse, except for the loss of his teeth. 
Various careful examinations, made at different times, failed 
to detect the presence of any foreign body, and the man him- 
self afterwards stated that he had always fancied the bullet 
fell out during his progress from the trenches to tlie regi- 
mental hospital. 

Injuries of the palate may also be produced by wounds of 
the face ; thus, Mr. Cox Smith, of Chatham, records the case 
of a soldier who came under his care, in whom the jaw and 
jialate had been extensively fractured, and the incisor teeth 



LODGMENT OF MISSILES. 



71 



driven in, as seen in fig. Sla, so that the patient was unable 
to masticate or speak. By extracting these teeth (fig. 31&), 
Mr. Smith was able to adapt a set of artificial teeth, so as 
to restore to the patient the use of his mouth for all pur- 
poses. 

Missiles, striking from without, occasionally lodge for a 
considerable time in the antrum or nose, and, sometimes, 
without their presence being suspected. In the " Medical 
and Surgical History of the Crimean War," will be found 
the case of a soldier who received a severe wound of the 
face. A grapeshot, weighing seventeen ounces, lodged in 
the jaw, having displaced the palate, with a portion of the 
maxilla, and all the molar teeth of the right side, into the 



Fic. 316. 




mouth. Here it was found necessary to enlarge the wound 
and remove the fragments (contrary to the general rule of 
practice) before the ball could be extracted, but the patient 
made a good recovery, notwithstanding severe secondary 
hsemorrhage. Still more remarkable, however, are cases 
which have occurred in civil practice, where the breech of a 
burst fowling-piece has lodged for years in the antrum. A 
remarkable case of this kind was reported in the Edinhurgh 
Medical Journal, of September, 1856, by Dr. Fraser, of New- 
foundland, who removed a piece of metal, weighing more 



72 GUNSHOT INJURIES OF THE JAWS. 

than four ounces, and measuring nearly three inches in 
length, from the jaw of a man who had sustained sun accident 
seven years before. A still more extraordinary case is re- 
corded in the Museum of Guy's Hospital, which possesses a 
model of the breech of a gun which had been lodged in the 
face of a man for twenty-one years ! " The patient was 
shooting birds when the gun burst, the right eye was knocked 
out, and the roof of the orbit destroyed, and through it the 
brain protruded ; the latter sloughed, and, after a long ill- 
ness, the man recovered. At the latter end of 1856 he was 
suddenly seized with symptoms of choking, as from a foreign 
body in the throat, and, on putting his finger in his mouth 
to remove it^ he drew forth the breech of a gun, much oxi- 
dized and covered with purulent matter. It is supposed that 
the piece of iron broke through the floor of the orbit, and 
had been lodging in the antrum ever since." 

In connection with this subject may be mentioned the case 
of a knife-blade lodged in the antrum for forty-two years, 
and finally coming out of the nostril, reported in the Bidlctino 
di Bologna, May, 1864. 

Cannon shot, striking the face, inflict the most frightful 
injuries upon the jaws, which are usually fatal ; thus Pro- 
fessor Longmore mentions (" System of Surgery," vol. i.) the 
case of an officer of Zouaves in the Crimea, who had the 
whole face and jaw carried away by a cannon-ball, the eyes 
and tongue being included, so that there remained only the 
cranium. The patient survived for twenty hours. Guthrie 
also relates a very similar case, as having occurred at the 
siege of Badajos. The wars of the first Napoleon af!brded 
some frightful examples of injury to the jaws, which the 
unfortunate patients survived for years in one of the 
military asylums of Paris. The accompanying drawing 
(fig. 32), taken from an able paper by M. Emile Debout, 
" On the Mechanical Piestoration of the Maxillaj" {British 
Journcd of Dental Science, April, 1864), shows the condition 
of a corporal who was struck by a cannon-ball at the siege 
of Alexandria, in 1800. The shot carried away the greater 
part of the face, including three-fourths of the lower jaw, 



INJURY FROM CANNON-BALL. 



73 



and part of the tongue, and the man was thought to be 
dead. Under the solicitous care of Baron Larrey he re- 
covered, however, and lived for more than twenty years. 
" It can be seen at a glance that speech and mastication were 
impossible. Poor Vaute concealed the deformity by wearing 
a mask, gilt inside, and imitating the colour of the skin 

Fio. 32. 




outside. He could even by means of this cover make himself 
a little understood, but his greatest distress arose from the 
incessant escape of the saliva, which was so great as to satu- 
rate in succession a number of linen compresses in the course 
of the day. After supporting his misfortune heroically for 
so many years, he put an end to his misery in 1821. In 
order to complete the history of a case in which he had felt 
so deep an interest, Larrey, on learning the death of Vaute, 
procured his head, the state of which he described. 

The loss of substance occasioned by the ball was limited 
to the elliptic segment seen in the portrait. The left malar 



74 GUNSHOT INJURIES OF THE JAWS. 

bone had been carried away. The arch of the palate and 
the nasal fossre down to the ethmoid had been destroyed. 
The inferior and internal orbital walls, down to the base of 
the skull, had been also destroyed. Two-thirds of the lower 
jaw were wanting. The right half of the middle portion of 
this bone, \vith three of the teeth, was found adherent to a 
part of the surface of the right ramus, which had been 
fractured. The portion supporting the coronoid process and 
the condyle was considerably depressed backwards to meet 
the other fragments of this bone ; but, as they were not in 
sufficiently close contact, they had not grown to each other. 
All the edges of the bones broken away by the ball had become 
thinned and rounded, forming, with the corresponding soft 
parts, a puckered, irregular border sun-ounding the gulf in 
the middle of the face. To perpetuate the history of the 
case. Baron H. Larrey has had the preparation of the head 
placed in the museum of the Hospital of Yal de Grace." 

Fragments of shell produce as frightful injuries as round 
shot, though the results are not so immediately fatal. Pro- 
fessor Longmore recorded {Lancet, 1855) a case of injury of 
the kind occurring under his notice in the Crimea, in which 
the right half of the palate was jammed in, and fixed at right 
angles to the other half, and the whole superior maxilla was 
much comminuted. The lower jaw was broken in three 
places, and there was extensive laceration of the soft parts. 
Great difficulty was met with at first in unlocking the parts 
of the palate which had been driven into each other, and 
when they were separated the right half hung down loosely 
in the mouth. The parts were carefully restored to position, 
and the patient made a good recovery without deformity. 

In the Appendix will be found the report of a case 
(Case V.) of extensive injury to the jaws by a piece of shell, 
in which Dr. D. Lloyd Morgan, Pi.X. (to whom I am in- 
debted for the report), was obliged to tie the common 
carotid artery for secondary ha^morrhnge, with success, so far 
as the operation was concerned, though the patient died of 
cholera some time after. 

A charge of small shot, if fired near enough to the face 



BULLET WOUNDS. 75 

to do more than lodge in tlie skin ov ja\v-)joiie (of wliicli 
there is a good example in the jMiddlesex Hospital Museum), 
will produce as serious injuries to the jaws as a bullet. In 
the Lancd of 10th November, 1860, is the report by Mr. 
Swete, of Wrington, of a case of very severe injury to the 
jaws from a charge of " dust shot," fired at a distance of 
four feet from the patient, a boy aged nine years. The 
charge entered the left side of the face, and passed out in 
front of the right ear, carrying away with it the greater part 
of the lower lip and jaw, and the v/hole of the chin. Several 
pieces of bone and teeth were picked up in an adjoining field, 
at a distance of ten yards. There was an extensive ragged 
wound of the face, extending nearly to the ear, the riglit half 
of the upper lip Ijeiug destroyed, and the teeth and alveolus 
of the same side carried away. The lower jaw was shot 
away at the angle on the right side, and on the left about an 
inch of the body of the jaw and one molar tooth remained. 
Mr. Swete trimmed the ragged edges of the jaw and brought 
the lacerated parts together, and, contrary to expectation, 
the patient recovered and, by means of a plastic operation, 
was restored to a condition of considerable comfort. 

Fracture of the lower jaw alone may be produced by 
bullets, and in this case the luemorrhage is often scN'ere 
from the divided facial artery, which vessel is generally in- 
volved. In the Edinhurgh Medical Journal, Sept. 1860, 
Dr. John Brown, of the Bengal IMedical Service, records four 
cases of the kind wliicli are good examples of tlie variety of 
injury inflicted by a bullet : — 

1. Was a gunshot injury of the jaw, attended by profuse 
haemorrhage. The facial artery was secured, and a large por- 
tion of the comminuted bone removed. The patient did well. 

2. "Was a gunshot wound at the symphysis. Tliere was 
a depression in the bone at the spot, but the ball had not 
perforated it. Did well. 

3. Occurred in Lucknow. A Sikh was shot in the right 
side of the lower jaw ; tliere was great arterial hsemorrhage 
from the facial artery, with a small wound over the angle 
and a larger one over the symphysis. Both were laid into 



76 GUNSHOT INJURIES OF THE JAWS. 

one, fragments were removed, and the facial artery tied. 
Died twelfth day. 

4. Ball traversed the mouth and fractured botli sides of 
the loM-er jaw near the angles. Died from pyaemia on twenty- 
first day. 

The Catalogue of the Surgical Section of the United 
States Army Medical Museum (1866) contains numerous 
records of injuries of this kind, from whicli the following 
may be quoted as most remarkable : — 

" 3350. The right half of the inferior maxilla fractured 
by a musket-ball, a small portion of which is attached. 
The missile entered the mouth, struck the alveolar ridge 
at tlie molar teeth, comminuting it, and causing oblique 
fi-acture of tlie body of the bone. Tiie patient died the 
same day from hjemorrhage, from rupture of the internal 
maxillary artery. 

"1451. Wet preparation of the right side of the body of 
the inferior maxilla, fractured and comminuted by a musket- 
ball at the angle. A fragment containing the molar teeth 
is driven inward, and other fragments remain in siiu, the 
total amount of bone shattered being two inches. The ball 
lodged in the thyroid cartilage, causing death by suffocation 
on tlie nineteenth day. 

" 3542. The inferior maxilla fractured and comminuted 
by a musket-ball. The alveolar ridge and the teeth are 
entirely removed ; there is a horizontal fracture of the left 
ramus passing through the inferior dental foramen ; on the 
right side there is a transverse fracture of the body of the 
bone at the last molar, and an oblique vertical fracture at 
the symphysis. The patient died from the effect of the 
wound of the tongue, causing hremorriiage, for which the 
left common carotid was ligated." 

The experience of English surgeons in the Crimea, already 
referred to, lias so completely settled the question of opera- 
tive interference in cases of gunshot wounds of tlie lower 
jaw, that few military surgeons would be inclined to follow 
the^ example of M. Baudens (see Guthrie's " Commentaries," 
p. 501) in laying open the cheek and removing or rounding 



FALSE JOINT IN THE LOWER JAW. 71 

off all fragments. Where spicula are much displaced, or 
where a bleeding vessel is to be reached, it may be occa- 
sionally necessary to enlarge the wound, as in one of the 
cases already quoted, but this must be considered the excep- 
tion rather than the rule. 

A fracture may possibly be produced indirectly without 
the bullet actually striking the jaw ; of this the following 
extraordinary instance occurred at the battle of Balaclava. 
A man of the 4tli Light Dragoons received a compound 
fracture of the lower jaw by a grape-shot striking the fiat 
of his sabre, while at the slope, and driving it against the 
side of his face and head. The blade was bent, but not 
broken, and the missile did not touch the man. 

Fragments of the jaw have been driven into other parts 
of the body, and even into that of a neighbour. In the 
" Medical and Surgical History of the Crimean War" is re- 
ported the case of a soldier who was shot in the right cheek, 
the ball glancing downwards and lodging in the neck, from 
which it was extracted. Subsequently a foreign body was 
detected behind the right clavicle, which was cut down upon 
and proved to be a portion of the lower jaw. Hamilton, 
also, in his " Mihtary Surgery" (p. 255), mentions the case 
of a Confederate soldier, who was kneeling and bending for- 
ward when he received a ritle ball upon his four lower in- 
cisor teeth. The ball and teeth disappeared, but were sub- 
sequently removed from beneath the skin at the top of the 
sternum. 

The frequent occurrence of a false joint after gunshot 
injuries of the lower jaw has been already adverted to in the 
section upon False Joint. Since in gunshot cases a loss 
of substance has usually taken place which renders the union 
of the remaining portions an impossibility, some mechanical 
contrivance should be adapted by the dentist to hold the 
parts in their proper position and enable the patient to mas- 
ticate. A case of false joint near the symphysis, treated in 
this manner most successfully by Mr. Cox Smith, has been 
already referred to, and will be found at page 31. Figs. 
33 and 34< sliow the effects of mechanical treatment in sepa- 



78 



GUNSHOT INJURIES OF THE JAWS. 



rating the fragments and the filling of the gap by artificial 
teeth, and should be contrasted with figs. 9 and 10. The 
sooner such apparatus is adapted after the receipt of the in- 



FiG. 3.3. 



Fig. 34. 




jury the better, since, as will be presently shown, the muscles 
have a constant tendency to draw the two sides of the jaw 
together. Not only is this effect produced upon the lower jaw, 
but there appears to be a secondary effect produced in these 
cases upon the upper jaw, the alveolar arch of which be- 
comes gradually contracted from Vt^ant of proper antagonism. 
M. Debout, in the paper already referred to, gives the case 
of a French corporal, who, during the Italian campaign, was 
wounded by a fragment of shell, which fractured the loM^er 
jaw and severely lacerated the integuments. The commi- 
nuted fragments were removed, and the soft parts brought 
together with sutures, so as to restore as far as possible the 
floor of the mouth. All that could be obtained, however, 
was to form a sort of channel concealed by the beard, as 
shown in fig. 35, by which the saliva flowed in great abun- 
dance. When the patient arrived at the A'al de Grace he 
was placed under the care of Professor Legouest, at whose 
request M. Preterre, the dentist, was called in. The latter 
gentleman, l)efore making any attempt to remedy the muti- 
lation by restoring the lower jaw, thought it necessary first 
of all to have an apparatus made for the purpose of pre- 
venting the contraction of the dental arch. Fig. 36 shows 



CONTRACTION OF UPPER JAW. 



79 



the apparatus in its place, A, c pointing to the position 
in whicli the alveolar border was wlien the case was first 



Fig 35. 




seen. The completion of the case M^as prevented by the 
patient quitting the hospital. 



Fig. 36. 




80 



GUNSHOT INJURIES OF THE JAWS. 



Complete or nearly complete destruction of tlie lower jaw 
by a cannon-ball lias more than once occurred, the patients 
survi\'ing for many years, and the deformity being palliated 
by the use of a silver chin (fig. 37). The accompanying 

Fig. 37. 




illustration (fig. 38) from M. Debout's paper, shows the dis- 
section of a case of the kind more than thirty years after 



Fig. 38. 




DESTRUCTION OF LOWER JAW. 81 

the receipt of the injury, the history being as follows : — At 
the battle of Jena, Vernet had the body and left ramus of 
the lower jaw carried away by a cannon-ball. The soft 
parts, bruised and torn, hung down in front of the neck, 
and the tongue was much injured from the tip along the 
left side. At the ambulance the parts were adjusted as well 
as possible, and the dressing completed. An abundant sup- 
puration ensued ; splinters were detached from the ex- 
tremities of the bones, and the whole was healed in three 
months. 

Eibes, in 1818, describes thus the condition of the parts 
when Vernet had attained the age of forty-four : — " The soft 
parts and loose flaps of the lips, chin, and cheeks have be- 
come agglutinated at the upper part of the neck, above and 
to the side of the larynx at the root of tlie tongue, where 
they form by their adhesion divers folds and cicatrices. 
The opening — the mouth — is situated beneath the arch of 
the palate ; the tongue lies concealed in the soft parts, and 
retracted towards the pharynx ; the lower part of the tongue 
is closely adherent, and in a manner fixed to the parts 
beneath it, so that the tip can be projected only to the left, 
and not forwards. 

" The patient wears a silver double chin, with which he 
can speak pretty distinctly ; but is much inconvenienced by 
the incessant escape of the saliva." — (Diet, des Sciences 
Medicales, vol. xxix. p, 435.) 

Vernet lived twenty years longer ; and some years before 
his death the mouth-opening became so narrow that, instead 
of being obliged to change the cloths or sponges, into which 
the saliva used to flow, five or six times a day, he scarcely 
wetted one. 

In this case the steady contraction of the cicatricial tissues 
of the mouth had a beneficial tendency. The effect pro- 
duced upon the teeth of the upper jaw is well seen in the 
illustration. 

In the United States Army Museum is a remarkable 
specimen of attempted bony repair of a nearly as extensive 
injury, which is thus described : — " 1162. The inferior 

G 



82 GUNSHOT INJURIES OF THE JAWS. 

maxilla, probably fractured by a musket-ball. The body of 
the bone has been removed nearly to the angle on each side, 
and an irregular plate of new bone, measuring two inches 
in length, three-fourths of an inch in width, and one-half 
inch in thickness has formed anteriorly, and is connected to 
the rami on either side by ligamentous bands. The patient 
died one hundred and one days after the receipt of the 
injury." 



83 



CHAPTER VI. 

DISLOCATION OF THE JAW. 

Dislocation of the lower jaw may be unilateral or bilateral, 
the latter being the more frequent v^ariety, since of 28 cases 
of dislocation given by Giralclfes, 15 were of both condyles ; 
and of 76 cases given by Malgaigne, 54 were the same, 31 
of these last being in women. Bilateral dislocation occurs 
most frequently in middle age, though it is not unknown in 
youth and old age ; thus Sir Astley Cooper gives the case of 
a child who experienced the accident from forcing an apple 
into his mouth, and both N(3laton and Malgaigne have met 
with it in old people of sixty-eight and seventy-two years 
of age. The possibility of dislocation of the jaw following 
traction on the chin with the finger or hook in delivery 
need be only alluded to, since the occurrence must be 
unknown, or nearly so, in the case of living children. The 
less frequent occurrence of the accident in the extremes of 
age may be explained, partly by the smaller liability of 
children and old people to external violence, and also by the 
fact that, owing to the obtuseness of the angle formed 
between the ramus and the body of the bone at those ages, 
the leverage of the jaw is diminished, and the muscles do 
not act in such vertical lines as in middle age. The expla- 
nation offered by M. Nc^laton — viz., that in youth the coronoid 
processes are too short, and in old age directed too far back, 
to impinge upon the malar process of the upper jaw — 
appears to be untenable, and will be referred to in describing 
the pathology of dislocation. 

The causes of dislocation are yawning, vomiting, or 
shouting, in all of which actions the patient's mouth is 

G 2 



84 DISLOCATION OF THE JAW. 

opened to its fullest extent ; or it may result from blows 
or the kicks of animals, and this is particularly the case 
with the unilateral form of the affection. Causes acting 
within the mouth may also produce dislocation — e.g., the 
introduction of an apple, as in Sir. Astley Cooper's case, 
already alluded to, or the introduction of the stomach-pump. 
Extraction of teeth, even in the most skilful hands, has been 
known to produce the accident, which has also been caused 
by the ordinary dental operation of taking a model of the 
lower jaw. (Salter, British Journal of Dental Science, July, 
1871.) Dr. Guignier, of Montpellier, has also reported 
{Abstract of Medical Sciences, vol. ii. 186G) an example of 
complete dislocation occurring during the laryngoscopic 
examination of a lady, aged thuty-eight, in whom reduction 
was readily effected. 

The pathology of dislocation of the jaw has been a sub- 
ject of considerable discussion and investigation from the 
earliest days of surgery to the present time, and various 
views respecting it have been brought forward by different 
authorities. When the mouth is opened to its fullest extent, 
each condyle of the jaw leaves the true glenoid cavity and 
rests against the articular eminence and the inter-articular 
fibro-cartilage, wdiich is drawn forward by the pterygoideus 
externus, the same muscle which advances the jaw itself. 
The articular eminence is covered by articular cartilage, 
and by the synovial membrane reflected between it and the 
cartilage, and a second synovial membrane being placed 
between the cartilage and the condyle of the jaw, the 
necessary freedom of movement is insured, A cavity is 
thus left immediately behind the condyle, which can be 
readily felt in the healthy living subject, and which is only 
exaggerated in cases of dislocation. When the jaw is in 
this position, but a very slight force is needed to carry the 
condyle over the articular eminence and produce a disloca- 
tiouj and this is brought about, either by a force applied to 
the chin, when, owing to the length of the lever, the result 
is readily induced; or by a spasmodic contraction of the 
external pterygoid muscles, which, as has been stated, are 



MECHANISM OF DISLOCATION. 85 

already in action. The lateral ligaments of the joints have 
no power to check this, and the few fibres which surround 
the synovial membrane and form a loose capsule are easily 
stretched, but never tear. The accompanying illustration 
from Sir Astley C coper's work on " Dislocations," shows 

Fig. 39. 




the position of the bone at this period, but is wanting in 
the ligaments and inter-articular cartilage, which latter is 
ordinarily carried forward with the condyle. Immediately 
that the condyles are dislocated the masseter and internal 
pterygoid muscles contract, and draw the jaw forwards and 
upwards so as to produce the projection of the chin charac- 
teristic of the accident. This last muscular action was 
originally described by Petit, and has been denied ; but has 
recently been confirmed by Heinlezn and Busch, who found 
experimentally on the dead body, that by replacing the 
muscles by india-rubber bands acting in the same direction 
as the muscles, the luxation could be invariably maintained 
and the characteristic deformity produced. 

Both Maisonneuve {L Union MecUccdc, 1863) and Otto 
Weber {o]). cit.), have experimented upon the dead body, 
and have succeeded in producing dislocation of the jaw by 
imitating the three movements already described, when the 
following is the condition of the parts found upon dissec- 
tion : — The condyles are in front of the root of the zygoma, 
the coronoid processes are completely surrounded by the 



86 



DISLOCATIOX OF THE JAW. 



tendons of the temporal muscles, and are quite below, and 
scarcely ever touch the malar bone. The capsular ligament 
is tense, but not ruptured ; the external lateral ligament is 
tense, and passes from Ijehind forwards instead of from be- 
fore backwards ; the internal lateral and stylo -maxillary- 
ligaments are stretched, and this is increased by raising the 
chin. The inter-articular fibro- cartilages are attached to and 
follow the motions of the condyles. According to Maison- 
neuve, the temporal muscles are only stretched ; but "Weber 
says that some of the fibres are usually torn ofif the coronoid 
process. 

The fixation of the dislocated jaw has received a different 
explanation, and has been attributed to the catching of the 
coronoid process against the malar bone, or the malar pro- 
cess of the superior maxilla. This view was originally main- 
tained by Fabricius ab Aquapeudente, by Monro, and more 
recently by Nelaton (Revue Medico-CliirurgicaU, torn, vi.), 
who is follow^ed by Malgaigne in his treatise on " Disloca- 

FiG. 40. 




tions" (1855). Nelaton maintains that in his experiments 
on the dead body he constantly found the coronoid process 



MEGHAN rSM OF DISLOCATION. 



87 



fixed against the malar bone ; and he appeals also to a 
unique preparation of a pathological dislocation which he 
dissected and presented to the Musee Dupuytren. The 
accompanying illustration (fig. 40), reduced from Malgaigne's 
Atlas, is from the preparation in question. The coronoid 
process in this certainly touches the malar bone, and the 
relations of the inter-articular cartilage and external lateral 
ligaments are well seen. 

Eibes and Monteggia agree with Maisonneuve and Weber 
in believing that in most jaws the coronoid process is not 
long enough to reach the malar bone ; and the last-named 
author mentions that Roser was unable to reduce an old dis- 
location of eight weeks' standing, even after cutting through 
both coronoid processes from within the mouth by means of 
bone forceps. From experiments I have myself instituted, 
I believe the view of Maisonneuve and Weber to be correct 
— viz., that the coronoid process does not become fixed 
against the malar bone. In the macerated skull it is easy to 
dislocate the condyle so far in front of the articular eminence 

Fig. 41. 




as to cause the coronoid process to be hooked against the 
malar bone ; but this is by no means easy on the subject, even 



0» DISLOCATION OF THE JAW. 

when tlie parts are dissected, and can only be accomplisiied 
by tearing the structures of tlie joint very considerably. 
Besides, the position the jaw assumes when the condyles 
are so driven forward, is not that of the ordinary form of 
dislocation, the jaws being too widely separated, and the 
chin drawn back instead of being advanced. Were the 
coronoid processes fixed against the malar bones, it would 
be impracticable to effect a reduction by elevating the chin, 
as is frequently done ; and, moreover, the gi'adual improve- 
ment noticed in old-standing cases of dislocation would be 
impossible. 

A preparation, illustrating the anatomy of dislocation, 
was dissected for me by my friend Mr. Marcus Beck, 
and from one side of it the drawing (fig. 41) was made. 

Symptoms of Dislocation. — When the dislocation is bi- 
lateral, the deformity is so evident as at once to attract 

Fig. 42. 




attention. The mouth is open and the jaw fixed, with the 
lower teeth carried beyond those of the upper jaw, as seen 
in fig. 42, from Fergusson. Speech and deglutition are much 
interfered with, since the lips cannot be approximated ; and. 



SYMPTOMS OF DISLOCATION. 



89 



for the same reason, the saliva dribbles from the mouth. 
On examining the neighbourhood of the temporo-maxillary 
joint, a distinct and unusual hollow will be seen immedi- 
ately in front of the ear, and the condyle may be both seen 
and felt in front of this. The coronoid process forms a 
projection immediately behind and below the malar bone, 
and may be readily felt in its abnormal position from the 
mouth. The masseter is firmly contracted and strongly 
prominent. E. W. Smith, in his work on " Fractures and 
Dislocations," has also specially called attention to a promi- 
nence immediately above the zygoma, which has not been 
usually described, and which he believes is due to the condyle 
pressing forward and stretching the posterior fibres of the 

Fig. 43. 




temporal muscle, but which I believe to be caused by their 
spasmodic contraction. The accompanying drawing (fig. 43), 
taken, by permission, from the work referred to^ illustrates 
both these points. 



90 DISLOCATION OF THE JAW. 

In dislocation of one condyle only the , signs are less 
manifest, and may possibly be overlooked or misinterpreted. 
The chin is usually directed towards the sound side instead 
of toward the injured side, as is the case in fracture of 
the neck of the bone ; the hollow in front of the ear is 
equally visible in this as in the double form of dislocation, 
and speech and deglutition are similarly to some degree 
interfered with. The obviousness of the direction of the 
chin to one side will depend in some degree upon the 
original prominence of that feature in the individual, and 
too much stress must not be laid upon the symptom : thus 
Hey, in his "Practical Observations in Surgery" (1814), 
remarks — " One would expect, from a consideration of the 
structure of the parts, and fi'om the descrij^tion given in 
systems of surgery, that the chin should be evidently turned 
towards the opposite side : but I have repeatedly seen the 
disease (accident) where I could discern no alteration in the 
position of the chin. The symptom which I have found to 
be the best guide in this case is, a small hollow which may 
be felt behind the condyle that is dislocated, which does not 
subsist on the sound side." K. W. Smith also mentions 
that, in a case of luxation of the right condyle, he had seen 
the efforts at reduction applied to the left side. 

Old-standing Dislocations. — From various causes disloca- 
tions of the jaw have been from time to time overlooked, 
and have not been brought under the notice of the surgeon 
for weeks or even months after the accident. Thus E. W. 
Smith (ojj. cit.) narrates the case of a woman who dislocated 
her jaw in an epileptic fit, whilst an inmate of one of the 
Dublin hospitals, but, the accident escaping notice, the bone 
remained imreduced. The drawing in Mr. Smith's work 
represents the condition of the patient one year after the 
accident, and it is to be remarked that though the signs of 
dislocation are sufficiently obvious in the hollow in front of 
the ear and the projection of the chin, yet that the patient 
was able to close the lips so as to retain the saliva and 
speak intelligibly, but was able to open the mouth only 
to a limited extent. 



OLD-STANDING DISLOCATIONS. 



91 



Mr. John Couper has recorded an equally interesting 
case in the London Hospital Reports, vol. i. p. 262. 
More than three months before, the patient had dislocated 
her jaw bilaterally (for the second time) whilst yawning, 
and when seen, she presented the appearance shown in the 
illustration (fig. 44), for which I am indebted to the editors 
of the Reports. Mr. Couper found that the jaw had re- 
covered a certain amount of mobility, so that the incisors of 
the two jaws could be approximated to within an inch, and 

Fig. 44. 




separated to an inch and a half, the molar teeth being 
nearly in contact during extreme closure. The chin was 
depressed and carried forward, and the hollow in front of 
the ear was well marked. The patient's utterance was 
slightly, if at all, impaired, and the labial consonants were 
pronounced as distinctly as other sounds, and the saliva was 
retained. Mr. Couper made attempts^ under chloroform, 



92 DISLOCATION OF THE JAW. . 

both with levers and forceps, to reduce the dislocation, but 
without success, but the effect of the operation was to in- 
crease the range of motion of the jaw. 

A second case of old double dislocation of the jaw oc- 
curred in the London Hospital in the year following Mr. 
Couper's, and, being of only two months' standing, was re- 
duced with some little difficulty by Mr. Hutchinson, who 
says {London Hospital Reports, vol. ii. p. 33) : " The woman 
was unable to shut her mouth, and her chin struck forward, 
giving her face an awkward, lantern-jawed expression ; but 
there was no wide gaping and she could easily shut her lips." 
The readiness with which the accident may be overlooked 
is illustrated by the concluding observation of Mr. Hutchin- 
son — " We had fancied at first that there was but little 
facial deformity, but this impression was corrected at once 
when we had her natural expression before us by way of 
contrast.'^ 

Probably the longest period which has elapsed after the 
accident and has been followed by successful reduction is 
four months, and this occuiTed in a woman in whom Mr. 
Pollock reduced the dislocation, by inserting wedges between 
the molar teeth and drawing up tlie chin by means of a 
strap-tom-niquet j)^'''S6d over the head. {St. Gcorr/e's 
Jlosjntal Ec'ports, vol. i.). 

Other examples of the successful reduction of old-standing 
dislocations have been from time to time recorded. Thus Sir 
Astley Cooper (" Fractures and Dislocations") gives a case in 
which Mr. Morley reduced a dislocation after a month and 
five days. Stromeyer had a similar case. Spat was successful 
in a case fifty-eight days old ; Demarquay in one of eighty- 
three days (Weber, op. cit.), and Donovan in one of even 
ninety-eight days {DuUin Medical Press, May, 1842). 

Earc Forms of Dislocation. — A few cases of rare forms of 
dislocation with fracture have been described. The cases 
recorded by Pobert of dislocation outwards with fracture on 
the opposite side, and by Mr. Croker King and Mr. Gun- 
ning of New York, of dislocation outwards and backwards 
with fracture of the symphysis, have been already referred 



TREATMENT OF DISLOCATION, 93 

to under the head of " fracture complicated by dislocation." 
It might be supposed from the anatomy of the parts that 
dislocation backwards would be impossible without fracture 
of the front wall of the meatus auditorius externus or of 
the glenoid cavity, and the specimen in St. (leorge's Muse-um 
(i. 28) is an instance in point. In Mr. King's case there 
can be little doubt that there was some injury to the meatus, 
from the hoemorrhage which occurred. 

Congenital Dislocations. — Cases of congenital dislocation 
of the lower jaw, with more or less malformation, have been 
recorded by Cruerin [Gazette Mklicale de Paris, 1841) and 
E. W. Smith ('^ On Fractures in the Vicinity of Joints'*), who 
gives alaborate drawings of the dissections of the case. 
Mention may be made also of the cases of congenital small- 
ness and arrest of development recorded respectively by 
Langenbeck {Archiv filr Klin. Chir., i.) by Mr. Canton {Patlw- 
logical Society's Trafisactions, vol. xii.), and Dr. Ogston's 
elaborate paper on " Congenital Malformation of the Lower 
Jaw," {Glasgoiu Medical Journal, 1875) ; but these subjects 
do not properly come within the scope of this work. 

Sah-luxation of the jaw was first described by Sir Astley 
Cooper, and has been generally recognised by surgical writers 
since his time. It will be described in the chapter on 
diseases of the temporo-m axillary joint. 

Treatment of Dislocation. — Although ordinarily requiring 
the assistance of the surgeon, dislocations of the jaw have 
been known to become reduced spontaneously, or with the 
aid of the patient alone. ISTelaton mentions a case of spon- 
taneous reduction occurring in his own practice ; and Sir 
Astley Cooper narrates the case of a lady who reduced a 
dislocation of one side, induced ]>y sea-sickness, with the help 
of an oyster-knife. Levison also gives the case of an old 
man who, suffering from recurring dislocation, especially 
when waking from sleep, " would pull his jaw and press it 
backwards, when, after about half an hour's work, bang it 
seemed to go, and all was right again." 

In recent cases of dislocation, reduction may usually be 
accomplished with facility by various methods of manipula- 



94 DISLOCATION OF THE JAW. 

tion, but cases of long standing may require some instru- 
mental assistance. The sim2)lest mode is for the head of 
the patient to be lield firmly against the breast of an 
assistant, while the operator, having protected his tluimbs 
with lint or a towel twisted round them, presses them as far 
back as possible upon the molar teeth, grasping the jaw at 
the same time with his fingers. Pressure is then made 
downwards and backwards, so as to free the condyles from 
the articular eminence, and as soon as tliis is done the chin 
is elevated and the condyles slip into place. This plan may 
be advantageously modified by reducing the condyles suc- 
cessively though at the same operation, care being taken 
that the condyle first reduced is not again dislocated, as has 
happened more tlian once. The proceeding is thus ren- 
dered easier, because one condyle forms a point of support 
or fulcrum for the other, so that the entire jaw is used as a 
lever, instead of the thumbs forming the fulcra, as in the 
other metliod. This latter method also obviates the danger 
of tlie jaw suddenly closing upon the thumbs, though this 
is probaljly somewhat exaggerated. 

Sir Astley Co(»per recommended the introduction of two 
corks (or one in tlie case of single dislocation) between the 
molar teeth to act as fulcra, the chin being then drawn 
uj^wards ; and narrates the case of a madman, where, for his 
own safety, he used two table-forks with a handkerchief 
wrapped round them to act as fulcra. Tlie same method 
was originally employed by Ambrose Pare, who used 
wedges of wood instead of cork, and his example has been 
followed by numerous surgeons. JMr. I'ollock employed 
this method successfully in 1860, in a ease of dislocation of 
four months' standing ; a gag being placed between the 
molar teeth, and the strap of an ordinary tourniquet being 
applied round the head and beneath tlie jaw, bo that the 
screw might exert its poAver upon the dislocated bone. 
{St. Georges IlospiUd licpoi'ts, vol. i.). 

Instead of mere fulcra having been inserted between the 
molar teeth, levers have been employed to depress the lower 
jaw in cases of difficulty; thus Sir Astley Cooper narrates 



stromeyer's forceps. 95 

that Mr. Fox, the dentist, " placed a piece of wood a foot 
long npon the molar tooth of one side, and raising it at the 
part at which he held it, depressed the point at the jaw on 
that side, and succeeded in reducing the condyle. He then 
did the same on the other side, and thus replaced the bone." 
Here, of course, the upper jaw formed the fulcrum, and the 
advantage of acting upon one condyle at a time is seen. 
Tliis method is not invariably successful, however, for in the 
case of old dislocation under Mr. Couper's care, already 
related, that gentleman employed levers of pine wood six 
inches long without success. 

A more powerful leverage action is obtained by the for- 
ceps invented by Stromeyer, whicli is shown in the illustra- 
tion (fig. 45). The forceps consists of two blades expanded 

Fig. -15. 




at the extremities, so as to fit pretty accurately the dental 
arches of the upper and lower jaws, and covered with leather. 
A spring between the handles tends to keep the blades 
closed, and a screw and nut, acting upon the handles, is 
able to close them so as to make the blades diverge forcibly ; 
at the same time a movable pin loosens this, so that the blades 
may be closed again the moment they have done their work. 
The blades being closed, and introduced between the teeth 
as far as possible, are then separated by means of the nut 
and screw, until the condyles are disentangled from the 
articular eminences, when, being suddenly closed, they are 
withdrawn, an assistant at the same time pressing the jaw 
backwards, so as to bring the condyles into the glenoid 
cavities. In this way Stromeyer reduced a dislocation of 
thirty-five days' standing. 

Nelaton, whose view with regard to the locking of the 
coronoid processes against the malar bones has been already 



96 DISLOCATION OF THE JAW. 

referred to, advocates acting directly upon these processes » 
in order to force them and the condyles backwards. The 
surgeon may stand in front of the patient, and, with his 
thumbs pressing against the coronoid processes, within or 
without the mouth, may grasp the mastoid processes with liis 
fingers, and tlius have a firm point cVapind to act from ; or, 
sitting behind the patient, he may place his thumbs on the 
nape of the neck, and endeavour to draw the jaw backwards 
with his fingers, 

Maisonneuve, though differing from Xelaton with regard 
to the pathology of the affection, agrees with him in the 
propriety of acting upon the coronoid processes. The fol- 
lowing were the conclusions he arrived at from numerous 
experiments on the dead body : — Blows on the cheeks or 
chin (whicli have been recommended in bygone days) were 
useless; pressure with the thumbs on the back teeth, com- 
bined with elevation of the chin, succeeded only a few times ; 
depression of the chin at the same time that the thumbs 
pressed away the masseters from the interior of the mouth 
was rather more successful ; depression of the chin and 
pressure on the coronoid processes from before backwards, 
with the thumbs in the mouth, effected reduction constantly 
and with ease. 

In November, 1883, Mr. Golding Bu-d brought before the 
Clinical Society a man aged twenty-tM'o, in whom an un- 
reduced dislocation of both condyles had existed for eighteen 
weeks. After breaking down adhesions Mr. Bird succeeded 
in reducing the right condyle, and subsequently the left, by 
Nekton's method of pressing directly upon tlie coronoid 
processes, followed by dra^^dng up the chin. 

In all cases of dislocation the administration of chloro- 
form will facilitate the reduction, but it is not necessary in 
recent cases. In old-standing cases it should invariably be 
had recourse t©, since the operation will necessarily be both 
painful and prolonged, in consequence of the formation of 
fibrous adhesions. 

When reduction has been effected, the precaution should 
be taken to limit the movements of the jaw for a week or 



TREATMENT AFTER REI)U(;T10N. 97 

two, by the use of the four-tailed haiidage used iu cases of 
fracture of the jaw. In individuals lialile to recurring dis- 
location of the jaw (like the woman mentioned by Putegnat, 
whose jaw was dislocated once a month), some elastic support 
for the chin should he employed, and care he taken not to 
open the mouth too widely. 

In the Lancet of April 14, 1883, Mr. Puglie, of Liverpool, 
has reported the case of a boy of four years, in whom the 
condyle was dislocated by a blow on the chin two years 
before, and in whom anchylosis between the condyle and 
the zygoma had taken place, causing complete closure of 
the jaws. Mr. Pughe resected, the condyle, with the result 
that the patient could open his mouth to the extent of an 
inch, but had no lateral movement. 



« 



98 



CHAPTER VII. 

INFLAMAIATIOX — ABSCESS PERIOSTITIS. 

Inflammation of the iDeriosteum leading to necrosis, and 
iuflammution in connexion with carious teeth leading to 
abscess, appear to be common to both jaws, but there is a 
form of inflammation to which the lower jaw alone is sub- 
ject, which requires notice. The inferior maxilla differs 
from the superior in consisting of two plates of compact 
tissue (of which the outer is the thinner) separated by can- 
cellous bone, tlu-ough which runs a canal for the passage of 
the inferior dental nerve and vessels, each of which gives 
an offset to each dental fang. When from the irritation of 
unsound teeth inflammation is excited, it rapidly sjoreads 
up the jaw, leading in a few hours to an amount of effusion 
into the cancellous structure which distends it, and forces out 
the external plate of the bone. This eff'usion, as I have had 
the opportunity of observing in my own person, is at first of 
discoloured serum, which by pressure on the jaw can be 
made to exude by the side of, or through, the hollow tooth 
which was the original cause of the mischief. If the source 
of irritation be allowed to remain, plastic effusion now takes 
place, leading to the formation of a distinct timiour, usually 
in the neighbom-hood of the offending tooth. This is slowly 
absorbed on the early removal of the tooth, but if the irrita- 
tion be allowed to continue, the effusion will become organized 
into fibrous tissue, and a very serious affection may thus be 
produced. From an attentive examination of numerous 
examples of fibrous tumour of the lower jaw, both before and 
after removal, I feel sure that the majority originate in the 
manner here described. 



ABSCESS. 99 

I had in the summer of 1867 a patient under my care — 
a boy aged fourteen — who was suflering from an enlarge- 
ment of the lower jaw, due to an expansion of its wall by a 
growth evidently connected with a carious permanent first 
molar tooth. I liad tlie peccant tooth extracted, but tlie 
enlargement of tlie jaw continued. In August some sup- 
puration occurred, and an abscess broke behind the angle of 
the jaw, but this soon healed, and in November he was 
perfectly free from pain and able to open the moutli 
thoroughly. I was anxious to perforate the jaw from tlie 
mouth so as to give exit to any fluid contained in it and 
extract any solid material which might exist, but the parents 
would not consent to any surgical interference. The face 
had in IMay, 1868, consideralily diminished in size, but 
there was still a difference between the two sides; two 
years later, however, I could detect no difl'erence between 
them. In a little girl of seven, also, wliom I saw in 1872, 
with great enlargement of the right side of the lower jaw, in 
six years the part had resumed its natural shape. Stanley 
in his work on tlie Bones (p. 20) says, " I believe tliat a 
bone once enlarged by the expansion of its tissue will per- 
manently remain so ;" 1 )ut this rule does not hold good with 
the lower jaw, which bone can most certainly undergo very 
considerable expansion and yet recover its original form. 

Abscess. — Inflammation, the result of diseased teeth, may 
lead to suppuration and abscess, and this may occur either 
as the ordinary Alveolar Abscess or Gum-boil, or as an 
abscess in the substance of the jaw, either upper or lower, 
which is a more serious affection. In ordinary Alveolar 
Abscess (jiarv.lis) the mischief begins at the apex of the fang 
of a carious tooth by an effusion of plastic material, around 
which, according to Salter (" System of Surgery," vol. ii.), 
a little cavity is formed by the absorption of the alveolus, 
often accompanied by some amount of absorption of the fang 
itself. A portion of this lymph becomes converted into 
pus, and the remainder forms a kind of sac around it, so 
that it occasionally happens that, on the extraction of the 
peccant tooth, the sac and abscess are brought away with it, 

H 2 



1 00 ABSCESS. 

So soon as matter is actually formed, rnpid absorption of tlie 
surrounding bone takes place, and tlie pus makes for the 
surface, finding an exit either at the side of the tooth, or by 
perforating the socket and burrowing in the soft tissues. 
The direction which the pus of an alveolar abscess may take 
is very variable. According to Salter the commonest position 
for tlie matter to point is "on the outer surface of the jaw at 
a point corresponding, as nearly horizontally as may be, with 
the extremity of the fang of the affected tooth, and 'piercing 
the gum within the mouth." But the matter may find its 
way on to the face, beneath the chin, or into the antrum, 
and, according to Tomes (" Dental Surgery"), " collections of 
matter, formed about the wisdom teeth, pass between the 
muscles and bone and escape at the angle of the jaw." Both 
Tomes and Salter mention the tendency of pus, derived from 
an upper incisor tooth, to burrow between the bone and 
periosteum of the hard palate and open upon the surface of 
the soft palate. The former also states that occasionally the 
pus separates the periosteum from one side of the hard 
palate, and forces it down to a level with the teeth. 

Abscess connected with the upper incisor teeth may also 
point within the nostrils by small orifices presenting little 
teat-like elevations, which will Ije at once detected on a 
careful examination of the nostrils. The patient's attention 
will have probably been directed to the occasional discharge 
of pus from the nose, and the case may, without care, be 
erroneously treated as one of oza?na. 

The early symptoms of alveolar al)scess are those of 
inflammation of the periosteum Kning the alveolus, and of 
the periodontal membrane of the tooth itself. There is a 
dull, obscure pain, relieved by biting upon the tooth, which 
appears to be raised slightly from the socket. The pain 
soon becomes of an acute, throbbing kind, and the consti- 
tutional symptoms are occasionally severe, amounting to 
high fever and delirium. The local symptoms are swelling 
and tenderness of the gum, and, according to Tomes, an 
early but evanescent symptom is a well-defined red ring 
encircling the neck of the tooth. The jaw becomes rapidly 



TREATMENT OF INFLAMMATION. 101 

swollen and the face consetxuently distorted, and the acute 
symptoms continue until the pus has found an exit, and 
then as rapidly subside. 

Treatment. — In the early stage, if the atfected tooth has 
been recently stopped, and more particularly if the nerve- 
pulp has been destroyed with arsenic, the stopping should 
be immediately removed, or a hole drilled into the pulp- 
cavity through the side of the tooth, so as to give exit to 
any accumulated fluid. (See paper on Ehizodontresis, 
by Mr. Hulme : Britisli Journal of Dental Science, April, 
1865.) 

Where there is no obvious exciting cause for the inflam- 
mation, the application of one or two leeches to the gum 
through a leech-tube, and the subsequent fomentation of 
the part by means of hot water held in the mouth, may give 
relief; but if this is not the case, or if there be an obvious 
local source of irritation, extraction of the tooth, or stump 
of a tooth, should be immediately performed. There is a 
popular notion, which has received some support at the 
hands of certain members of the profession, that extraction 
of a tooth must not be performed during the stage of active 
inflammation of the alveolus. I know of no foundation for 
this- statement, which is entirely devoid of trutli, and yet it 
has formed the ground for an action against an eminent 
member of the dental profession. It may be well, there- 
fore, to put on record the statement of the President of the 
" Association of Surgeons practising Dental Surgery,^' in 
answer to the cpiestion, " Is it right to refuse to extract a 
carious and aching tooth on account of the acuteness of the 
periosteal and maxillary inflammation which its presence 
has excited ?" The President (Mr. Cattliu, F.E.C.S.) " was 
glad that Mr. Owen had brought under discussion, in his 
practical paper, an unskilful kind of practice which greatly 
increased human suflering, and was often very injurious to 
the patient in after-life. It was the erring practice of some 
to wait until the inflammation subsided ; but if the tooth 
be retained, the swelling, as a rule, rapidly extends to 
adjoining parts, and sometimes causes necrosis, occasionally 



102 ABSCESS. 

iiililtmtion into muscles, restrictiii<^' the movements of the 
jaw, iiud often ending in abscess, which, bursting externally, 
permanently disfigures the face." {Medical Press and Cir- 
cular, January 12, 1881.) 

When matter has formed, and is finding a precarious exit 
by the side of the tooth, whicli is certainly dead and M'ill 
only prove a source of irritation, its immediate extraction is 
the best practice. But when, as frequently happens, the 
matter has perforated the alveolus, and passed into the sub- 
stance of the glim so as to produce an elastic fluctuating 
tumour between the teeth and the cheek, a free incision 
into it is the best and only mode of treatment ; and in 
these cases, if the hole in the alveolus is sufficiently large 
to give free exit to the pus, the tooth may be eventually 
saved. I know of no reason for delaying tlie incision until 
the gum has become distended with pus, though the practice 
has its advocates. So soon as inflammatory swelling takes 
place, an incision will do good by relieving congestion and 
giving exit to exudations ; and I have never seen reason to 
regret an early and free incision in such cases. A sharp 
scalpel or small bistoury is the best instrument for the 
operation, the ordinary gum-lancet being unsuitable and 
inconvenient for the purpose, and no damage to neighboimng 
parts can happen if the edge of the knife is directed to- 
wards the bone. I have once known the facial artery 
wounded from within the cheek, from neglect of this pre- 
caution. 

In cases of abscess arising from the upper incisor teeth 
and extending along the palate, a free and early incision is 
even more necessary than in the ordinary form of abscess, 
since extensive necrosis and exfoliation of the hard palate, 
with consequent perforation, may not improbably result 
from the delay. The same rule holds good also in all cases 
of matter pointing within the cavity of the mouth ; but 
where, as has already been mentioned, the matter shows a 
tendency to point on the skin of the face or neck, every 
means should be taken to avert, if possible, the opening in 
tliis situation, and to insure an exit for the matter within 



TREATMENT OF ABSCESS. 103 

the mouth. In order to fiifil the latter indication, which 
is most essential, the tooth or stump which has been the 
cause of the mischief should be immediately extracted, and 
a deep incision made through the gum near the spot where 
the matter points. It may be well to notice here, tliat the 
cause of the abscess in these cases is not unfrequently over- 
looked, owing to the distance between the tootli and the 
point where the matter appears, and that, in all cases there- 
fore of abscess about the jaws or neck, it is well to investi- 
gate carefully the state of the mouth. 

On two occasions I have known death result from a low 
form of cellulitis spreading between the muscles of the 
neck and leading to cedema of the larynx, distinctly trace- 
able to neglected alveolar abscess, in patients whose consti- 
tution had been greatly damaged by intemperance. In the 
first, I had made free incisions in the mouth and neck, but 
cedema giottidis supervened in the night and proved fatal. 
In the second, I took the precaution of freely scarifying the 
mucous membrane of tlie throat, but here again, unfortu- 
nately, I was not summoned when the breathing became 
urgent. I would strongly advise in a similar case the early 
performance of laryngotomy as a safeguard, in addition to 
free incisions. 

No greater mistake can be made than to encourage the 
pointing of an alveolar abscess on the surface of the skin by 
poulticing. During the early and acute stage of the inflam- 
mation, the warmth of a poultice may be grateful to the 
patient, and if applied for a few hours will do no harm, 
though I should myself greatly prefer the application of 
extract of belladonna and glycerine in equal proportions ; 
but continued poulticing will merely lower the vitality of 
the part, and tend to the very result which is to be avoided 
if possible. Even when the skin is already reddened and 
adherent to the bone, its breaking may be avoided (provided 
a free exit for the discharge of matter into the mouth has 
been secured) by painting the surface with flexile collodion 
or with the tincture of iodine, all warm applications being 
discarded. 



] 04 ABSCESS. 

The sinuses left after an alveolar aljscess has burrowed 
through the integuments, remain open so long as the cause 
of irritation is untouched, and the orifice though con- 
tracted never closes, being surrounded by granulations which 
sometimes grow to a large size. I recently had under my 
care a girl who was brought to me for the supposed growth 
of a horn from her chin, and the appearance was not unlilvc 
one of the horn-like growths of cuticle occasionally met with. 
It proved to be nothing more than a growth of epithelium 
on the top of long granulations around a fistulous opening, 
due to the presence of a stump in the lower jaw, the bone 
having been perforated by the abscess. The successful 
treatment of these sinuses, like tliose dependent upon the 
presence of dead bone elsewhere, can only be insured by the 
extraction of the ofi'ending tooth or stump. In these cases 
the fang is necrosed and forms a sequestrum in the same 
way as a piece of bone, and will keep up irritation so long 
as it is allow^ed to remain. The distance from the jaw at 
which an alveolar abscess may occasionally point not un- 
frequently leads to mistakes in diagnosis and treatment, 
particularly of the resiilting sinus. I have on several 
occasions known a sinus, at some distance below the lower 
jaw, treated by injections when the fang of a tooth was 
keeping up irritation, and Salter has seen openings an inch 
below the clavicle dependent upon the same cause. I have 
once found the diseased fang so deeply buried and over- 
lapped by the neighbouring teeth that it could only be 
detected by careful probing from the inouth, and it w'as 
necessary to remove the adjacent tooth in order to reach the 
cause of the sinus. 

Abscess may form in the substance of the upper or lower 
jaw as a consequence of decayed teeth, but differing from 
ordinary alveolar abscess in the absence of any tendency to 
find an exit by the socket of the tooth. In the upper jaw 
this affection has been confounded witli the so-called 
"abscess of the antrum," which is more properly an em- 
pyema, and which will be subsecpiently discussed ; and Otto 
Weber {Allriemcincii unci sjjcciellen Chirurgic, iii.) strongly 



ABSCESS OF LOWER JAW. 105 

in;iiiitains that abscess luay form in the wall of the antrum, 
but })erfectly separated from it l)oth by the periosteum 
and the mucous membrane, or sometimes by a plate of 
bone. 

Abscess in tlie substance of the lower jaw has been more 
frequentl}' met with : thus Mr. Annandale, of Newcastle, met 
with a case of chronic abscess in the left side of the lower 
jaw of a boy aged ten, resulting apparently from repeated 
blows upon the part. Owing to the great thickening of the 
bone the abscess was not diagnosed, and the half of the ja^v 
was removed, the boy making a good recovery. The tumour 
was of the size of an hen's egg, and extended from the first 
bicuspid tooth to the articulation. On section, the bone was 
found to be very dense, and contained a cavity of the size 
of a horse-bean, tilled with pus, and lined by a distinct 
membrane of some thickness. (Edhiburgh Medical Journal, 
December, 1860.) In a lady whom I saw with Mr. G. 
Bateman, there was a fluctuating swelling ol the lower jaw 
in the incisive region, from which I evacuated by incision a 
quantity of offensive inspissated pus, a " residual abscess" 
due to irritation from incisor teeth which had been extracted 
some time before I saw the patient. 

xVnother mode in which abscess may be formed in both 
the upper and lower jaws is by the suppuration of a 
" dentigerous cyst" connected with non-developed or im- 
perfectly developed teeth. A remarkable case of this kind 
is reported by Weber {pp. cit^ in which a woman, aged 
twenty-five, shortly after the partial eruption of a wisdom- 
tooth, found a tumour forming on the left side of the jaw, 
which in a year extended from the mental foramen to 
beyond the angle. The bone gave a crackling sound \\'\\q\\ 
pressed upon, and in one or two situations appeared to 
be entirely aljsorbed. An incision was made over it and 
the tissues turned aside, and on opening the tumour three 
ounces of thick flaky pus poured out. Part of the wall 
was removed, and the patient made a good recovery. 

Probably the case described by Liston in his " Elements 
of Surgery" (p. 419), in which he mentions that osteo-^ 



106 PERIOSTITIS. 

sarcoma may supervene on " spina ventosa" of the lower 
jawj is an instance in point. The case was that of a young 
man, aged twenty-one, who had an abscess of the lower jaw in 
the molar region, which was evacuated through the mouth, 
and by means of a seton. Two years after, the abscess refilled, 
and again after another year ; osteo-sarcoma then developed, 
necessitating the removal of half the jaw. 

A remarkable specimen is in the j\Iuseuni of King's 
College, of a large abscess of the lower jaw, for which half 
the bone was removed by Sir William Fergusson. The speci- 
men has been divided and one half put up wet, showing the 
immensely thickened wall of the cavity ; the other having 
been macerated, show^s merely tlie shell of expanded and 
partially absorbed bone. The disease had followed an attack 
of erysipelas of the face and tooth-ache, and continued to 
increase for eleven years, discharging at intervals offensive 
matter. 

Periostitis. — The jaws, no less than other bones of the 
skeleton, are subject to periostitis, which may be of the 
acute or chronic variety. The acute form may arise from 
the irritation of decayed teeth, or in young subjects from 
cutting the permanent teeth ; from mechanical injury ; or 
may be induced by a specific poison, such as that of the 
exanthemata, of mercury pushed to salivation, or the vapour 
of phosphorus. In strumous children, however, periostitis 
may occur without any obvious cause, except a constitutional 
taint, which leads, as we frequently see, to periostitis in 
other parts of the body. 

Mr. Stanley, in his work on " Diseases of the Bones" 
(p. 71), alludes to cases of this kind, though he does not 
appear to connect them witli a strumous diathesis. He 
says, " A large portion of the lower jaw in young persons 
occasionally perishes without any previous derangement of 
health, local injury, or other apparent cause. But in some 
cases an aching in the bone has preceded the death of it. 
Such examples of necrosis usually occur in early life, between 
the fourth and twentieth years, but rarely later." 

The symptoms of periostitis are pain, which is aggra- 



PERIOSTITIS. 107 

vated at night ; heat of the part, with considerable swelling 
of the face and constitutional disturbance ; the teeth are 
found to be raised somewhat from their sockets and 
loosened, and the least pressure upon them gives excru- 
ciating pain. 

In all these cases the tendency of the inflammation to 
run on to suppuration, and thus induce necrosis of the bone, 
is so great that tlie disease is often not recognized in its 
early stage, but should it be so, the treatment relied upon 
in other parts of the body would be applicable here — viz., 
local depletion by leeches, a free incision through the 
affected periosteum to give exit to effusion, followed by 
poppy fomentations, and the exhibition of salines and 
sedatives. 

The more chronic form of periostitis is usually of sy[)hi- 
litic origin, and leads to the formation of nodes here as in 
other parts. The palate is especially liable to these swell- 
ings, which are due to effusion between the periosteum and 
the bone, and which, if left untreated, will as surely lead to 
necrosis as the more acute forms. Mercury is inadmissible 
in these cases, but iodide of potassium in full doses will 
rapidly remove the swelling, and restore the periosteum to a 
healthy state. 

The simple form of periostitis, which will lead to abscess 
and perhaps necrosis, is sometimes very insidious in its 
approach, and the intermittent pain, recurring usually at 
night, may mislead as to the original cause of the attack, 
the examination of the teeth being neglected, and the 
attention concentrated on a supposed constitutional diathesis. 
It is well, therefore, in all cases of supposed periosteal 
inflammation, to examine the condition of the teeth, both 
with the eye and by striking them pretty forcibly, and any 
tender tooth should be removed ; since, according to Tomes, 
a greater or lesser degree of exostosis of the tooth itself is 
pretty certain to have taken place, which will keep up the 
irritation. 

Dr. Gross, of riiiladelphia, has called attention to a form 
of neuralgia occurring in edentulous jaws, and dependent 



108 PERIOSTITIS. 

Upon thickening uiid induration of the alveohir margin, by 
which the remains of the dental nerves become compressed 
and irritated. He recommends removal of the margin of 
the alveolus with cutting forceps, and speaks highly of the 
practice. Having seen the proceeding adopted on several 
occasions by Mr. Erichsen, and having used it myself, I 
think that there are undoubtedly cases of neuralgia which 
are relieved by the treatment, but that it is by no means 
of universal application in cases of neuralgia of the fifth 
nerve. 

Caries of the jaws of idiopathic origin may be said to be 
unknown, for, as pointed out by Fergusson, the term caries 
ought not to be applied to the ulcerations met with in con- 
nection with the formation of abscesses or the separation of 
sequestra. In cases of ulceration and extensive destruction 
of the tissues of the face by s}-pliilis or lupus, the jawbones 
are sometimes in^'olved and become carious, producing 
the most frightful deformity ; or in the case of syphilis 
(probably niercurio-syphilis in former years), the disease 
may begin in the palate and gradually destroy it, laying 
the mouth and nose into one, and passing forward to the 
face. 

In the ^Inhic fur Patlwloyischc Anatomic, xviii. 347, 
Dr. H. Senftleben has given an elaborate description of what 
he terms acute rheumatic periostitis of tlie lower jaw, which 
appears, however, to differ in no essential particular from 
the ordinary form of acute periostitis following exposure, 
&c. He says that it attacks perfectly healthy and robust 
individuals with good teeth,, after severe cold, commencing 
with violent toothache along one side of the lower jaw, con- 
siderable and often very intense fever, swelling of the cheek 
and gums, difficulty in chewing, &c. Active dej^letion in 
recommended, and an early incision if matter forms, but 
necrosis is a Aery frequent consequence. {Sjjdcnham 
Society's Year Bool; 1863, p. 259.) 

Magitot, in a paper read before the Academy of Medicine 
of Paris (1882) has described a form of alveolar ])eriostitis, 
which he considers pathognomonic of diabetes. Without 



DlABI^ync PRi;iOSTITJ,S. [()[) 

going so far as this Dr. Pavye reognizes the aft'ectiou in the 
following extract from his work on Diabetes : — 

"The teeth are not unfrequently observed to become 
loosened in diabetes, and it may lie even to such an extent 
as easily to drop out. There is evidently some direct con- 
nection between this phenomenon and the disease. It seems 
as if the morbid condition of the system prevailing interfered 
with the nutritive action going on in the fang and its socket, 
and so led to the result. It is only when the symptoms are 
allowed to run on in a severe form that it is noticed, and 
supposing the teeth to have become already loosened, I have 
known them again become firm upon the disease being con- 
trolled by treatment." 



no 



CHAPTEE YIII. 

NECKOSIS OF THE JAWS. 

The jaws nre specially liable to necrosis consequent upon 
inflammation, but there is a difference in the frequency with 
which the upper and lower jaw is attacked. According to 
Stanley (" Diseases of the Bones," p. 69), the order of fre- 
quency of necrosis of the bones of the skeleton is as follows : — 
Tibia, femur, humerus, flat cranial bones, loioer jaw, last pha- 
lanx of finger, clavicle, ulna, radius, fibula, scapula, uiiper 
jmr, pelvic bones, sternum, ril)S ; and the greater immunity 
enjoyed by the upper as compared with the lower jaw is due, 
no doubt, partly to its less exposed position, but more espe- 
cially to the fact that necrosis occurs less frequently in can- 
cellous than in compact bone. The great difference in the 
supply of l)lood to the two bones must also have an influence, 
tlie upper jaw being supplied by very numerous branches of 
the internal maxillary arteries, which inosculate freely from 
side to side, whilst the lower jaw is supplied by two small 
branches only, which do not anastomose. 

The causes and early symptoms of necrosis are usually 
those of periostitis, and have been described under .that 
heading. When the inflammation fails to be arrested, the 
plastic effusion between the periosteum and the bone be- 
comes rapidly converted into pus, and this, by separating the 
membrane from the bone, soon leads to the death of the 
latter. In long bones, where there is a medullary canal 
abundantly supplied with blood, or in the upper jaw where 
the vascularity is great, the bone is able to resist this ne- 
crotic action for some time, and even to recover, although 
bared of periosteum for a while ; but in the lower jaw 



SYMPTOMS OF NECROSIS. 



Ill 



tliis cannot be expected, and it is found that a very few 
hours after suppuration has been excited, the bone is in great 
part necrosed. This action does not extend, however, of 
necessity to tlie whole tliickness of the jaw, for the disease 
ahnost invariably attacks the outer side of the bone first, and 
if timely relief be afforded to the pent-up matter, the peri- 
osteum on the inner side will escape injury, and that portion 
of the bone will be preserved. Or, even if the disease affect 
the whole thickness of the bone, it may still be confined to 
the alveolar border, which may exfoliate leaving the base of 

Fig. 46. 




Ftg. 47. 




the jaw intact. Of this an excellent example is preserved 
in the Museum of the College of Surgeons in Dublin, where 
an unbroken exfoliation of the entire alveolar arch of the 
lower jaw, with the teeth still in it, closely resembles a set 
of artificial teeth. In the upper jaw also the disease may 
attack one part of the bone, the rest being intact, and thus a 
sequestrum may be formed from either the alveolus or the 



112 NKCRORIS OF THE JAWS. 

palatine plate, or occasionally from both, of which a good 
example i.s seen in the preceding woodcuts, for which I 
am indebted to Mr. Nicholson, of Liverpool, fig. 46 showing 
the alveolar border, and fig. 47 the palatine plate of the 
sequestrum. When the ]3us resulting from tlie inflammation 
is unrelieved by timely incision, it tends to gravitate and 
find an exit for itself at the most easily reached surface. 
Thus, in the case of the upper jaw the tendency of the 
matter is to burst into the mouth, and it is tlie exception to 
find openings on tlie face, except when the whole of the 
bone is involved. In the case of the lower jaw, on the 
contrarv, the matter finds numerous openings for itself along 
the lower margin of the lione, on its outer aspect, and even 
at some distance down the jieck. 

The effect of n<?crosis of the jaw ujion tlie teeth is easily 
seen, since in cases of entire necrosis they become loose and 
discoloured^ and even in ]3artial necrosis tliey cannot bear 
the least pressure, owing to the pain produced. In the 
majority of cases of necrosis the loose teetli prove such an 
annoyance to the patient that they are extracted, if they do 
not drop out of their own accord ; but cases have been met 
witli, and M'ill be snl)sequently referred to, in wlncli the 
teeth remained in situ long after the l3one was Ijoth necrosed 
and had been removed. In the case of young subjects, ex- 
tensive necrosis of tlie jaw will ordinarily destroy the germs 
of the permanent teeth as well as the temporary teeth already 
cut, and of this a good example is to be seen in the Museum 
of St. Mary's Hospital, in a sequestrum of the lowei' jaw from 
a girl of from three to four, after small-pox. Tlie necrosis 
involves tlie whole of the right side of tlie body of the bone 
and a portion of the ramus, including five temporary teeth 
and the half-developed permanent teeth, and, reaching beyond 
the symphysis, includes a portion of the outer plate of the 
left incisive region. But it has occasionally happened, after 
repair of the bone in young subjects, that the ])ermanent 
teeth have been cut, thus leading to the supposition of a re- 
production of the teeth as well as of the bone. Mr. Tomes 
has pointed out, that in these cases the sequestrum did not 



NECROSIS OF THE JAWS. 113 

involve the pulps of tlie permanent teetli, although encroach- 
ing upon them, and they therefore remained in sitir, -whilst 
the new bone was formed around them, and the teeth, when 
fully developed, made their appearance in the ordinary 
way. 

From a consideration of these cases Mr. Tomes draws the 
following valuable practical deductions as regards tlie treat- 
ment of necrosis of the young jaw, which may be usefully 
referred to at this point : — " I tbink all will agree that it is 
desirable in those cases where necrosis of the jaw occurs 
during the presence of the temporary teeth, that the seques- 
trum should be allowed to remain until it is perfectly de- 
tached both from the contiguous bone and soft parts, before 
its withdrawal is attempted ; and that its removal should be 
effected with the least possible injury to the latter, so that 
the permanent teeth, if not destroyed by the disease, may 
be placed under the most favourable circumstances for their 
future growth and evolution." (" Dental Surgery," p. 75.) 

In 1868 Mr. Oliver Chalk brought before the Odonto- 
logical Society some cases which, in his opinion, proved 
that a fresh development of teeth might occur even after 
the jaw, together with the germs of the second set, had been 
removed by necrosis. Having had the opportunity, how- 
ever, of hearing the paper in question, and of examining Mr. 
Chalk's preparations, I must remain of my previous opinion, 
which coincides with that of Mr. Tomes — that such an event 
is impossible, and that the germs of any subsequently cut 
teeth must have been preserved, and become enclosed in the 
reparative material of the jaw. (See British Journal of Dental 
Science, Feb. 1868.) 

A specimen of necrosis, which accompanied this essay 
(College of Surgeons Museum, 1440) was from a boy 
named Barton Blackman, who subsequently came under my 
care with closure of the jaws by cicatrices, and was removed 
by the late Mr. Martin, of Portsmouth, in 1856, when the 
boy was ten years old. He had extensive necrosis of both 
jaws after fever, and the portions of sequestra preserved show 
exceedingly well the relation of the permanent to the tem- 

I 



114 



NECROSIS or THE JAWS. 



porary teeth ; in some instances the partly-formed second 
tooth having come away, and in otliers being left behind. 

Eo:anthemc(tous Necrosis. — Under this name, Mr. Salter 
has descriljed {Guifs HospitaJ Bcports, vol. iv., and System 
of Surgery, vol. ii.) the form of necrosis of the jaw in chil- 
dren which depends upon the poisonous effects of some of 
the exanthematous diseases, and especially scarlet fever. 
Mr. Salter claims to have been the first to call attention to 
this form of necrosis, and to trace it to its cause, and has 
met with over twenty instances of the affection. In the Pa- 
tlwlogiced Society's Transrictions (vol. xi.), he has described 
and figured seven specimens of the exfoliation — four after 
scarlet fever, two after measles, and one after small-pox. 
The disease appears to occur most frequently about the age 

Fig. 48. 





A, autei'ior ; B, e.xternal ; c, internal view of inter-maxillaiy bones. 

of five or six years, when each jaAv contains the whole of the 
first set, and the germs, more or less advanced, of the second 
set of teeth ; but Mr. Bryant has recorded {Pcdhological 
Soc. Trans., vol. x.) a case of exfoliation of the intermaxil- 
lary bones after measles, in a child of three (fig. 48), and 
the boy Barton Blackman, already referred to, is an instance 
of the kind, at the age of ten. 

The disease first shows itself a few weeks after the occur- 
rence of the feverish attack, in tenderness of the mouth and 
fcetor of the breath, and the gum is seen to be separated 



EXANTHEMATOUS NECROSIS. 115 

from the teetli and alveolus. Tlie disease is remarkably 
symmetrical, appearing almost simultaneously on both sides 
of the jaw, and rapidly denuding the bone, thus leading to 
necrosis and subsequent exfoliation of considerable portions 
of it. These usually iuclude the whole depth of the alveolus, 
together with the partially-developed permanent teeth ; but 
no case has been met with in which the lower border of the 
jaw was involved. 

It is possible that this disorder might be confounded with 
cancrum oris in its early stage, but the absence of ulceration 
of the gum would at once distinguish it. 

I am indebted to Mr. N. Tracy, of Ipswich, for a prepara- 
tion of necrosis follo\ving scarlet fever, in a girl of thirteen, 
which accompanied this essay (College of Surgeons Museum, 
1441). The disease was, as usual, symmetrical, but the 
right side was more deeply involved than the left. On the 
right side the sequestrum, 1^ inch in length, and | inch in 
depth, contained the permanent first molar and the uncut 
permanent bicuspid teeth, besides a temporary molar ; and 
involved part of the socket of the second permanent molar 
behind, and of the canine in front. On the left side the 
disease involved only a portion of the alveolar border, in- 
cluding a temporary molar tooth. A model, taken three 
years later, showed the permanent gap left Ijetween the 
canine and the first molar teeth on the right side. 

A very remarkably extensive necrosis of the lower jaw, 
occurring in a child of four, is shown in fig. 49, taken, by 
permission, from a specimen brought before the Pathological 
Society by Mr, Waren Tay {Pathological Sac. Trans., 1874). 
The sequestrum includes the whole lower jaw, with the ex- 
ception of one condyle, and the subsequent repair seems to 
have been very complete. The cause of the mischief appears 
to have been doubtful, but may have been due to the trick 
of suckino- lucifer-matclies, in which tlie child is said to have 
indulged. Mr. Tay brought this patient again before the 
Pathological Society in November, 1883, when there was a 
firm ring of new bone present in the situation of the jaw, 
quite firm enough to give support to artificial teeth if they 

I 2 



116 



NECROSIS OF THE JAWS. 



were supplied. At the posterior part of the left side a sharp- 
edged tooth has made its appearance lately. He could depress 
and elevate the jaw vigorously. On the left side, where the 
condyle was wholly removed, there was good lateral move- 
ment, but on the right side the movements were not so free, 
though lie had no difficulty in chewing food. 

Mr. Salter regards necrosis after continued fever as of 
rare occurrence. In the Guy's Hospital Museum, however, 
is a portion of lower jaw (1091, vii.), consisting of condyle, 
angle, and part of the body of the bone, separated by 

Fig. 49. 




necrosis after fever, from a boy of fourteen. He recovered 
with comparatively trifling deformity, and the skin remained 
sensitive, although a large part of the trunk of the nerve 
must have been destroyed. In St. George's Hospital 
Museum also there are specimens (II. 91 and 95) of necrosis 
of the lower jaw and clavicle in fever. A case of very ex- 
tensive necrosis occurring after fever, under Mr. Stanley's 
care, will be referred to further on. 

The repair of extensive necrosis of the alveolus of this 
character, in young persons, is a subject of some interest. 



REPAIR AFTER NECROSIS. 117 

In the lower jaw no repair of the gap is necessary, since,-' 
fortunately, the disease leaves the strong lower border of the 
bone untouched, which preserves the contour of the face, and 
forms a base for artificial teeth at a later date. In the 
case of the upper jaw, however, a development of tough 
jfibrous tissue takes place, which gradually fills up pretty 
completely the cavity left, and thus, to a great degree, pre- 
vents the falling in of the cheek and consequent deformity 
which would otherwise occur. In the Museum of King's 
College is a preparation of the nearly entire upper jaw of a 
child, which became necrosed as a consequence of small-pox, 
and was removed by Mr. Partridge, when surgeon to the 
Charing Cross Hospital. By the kindness of Mr. Canton, 
I have had access to a photograph of this patient, taken 
within the last few years, which shows the very slight de- 
formity now present, in consequence of this repair of the 
original mischief. 

This statement respecting the repair of a necrosed superior 
maxilla is, at first sight, in opposition to the opinion of 
Stanley ("On Diseases of the Bones," p. 72), who says, 
" under whatever circumstances the necrosis has occurred, it 
is not, as I believe, ever followed by the slightest reproduc- 
tion of the lost bone." This I believe to be true quoad 
the reproduction of actual bone, and in the case of adults, 
but the filling up of the cavity by fibrous tissue I have wit- 
nessed in young subjects after the removal of tumours. 

The case upon which Mr. Stanley founds the above ob- 
servation is a remarkable one, from the apparent want of 
cause for the extensive mischief that ensued. The patient 
was a man aged thirty, who, twelve months before he applied 
to Mr. Stanley, began to suffer pain in his upper jaw, soon 
after which the teeth fell out of their sockets, and matter 
was discharo-ed into the mouth. When the dead bone was 
sufficiently loosened, Mr. Stanley drew away the greater 
part of both superior maxilhu. 

A very similar case occurring in a strumous man, aged 
forty, is recorded by Mr. Ernest Hart, in the Lancet, 19th 
July, 1862, and, by the kindness of that gentleman, I am 



118 



NECROSIS OF THE JAWS. 



enabled to reproduce the drawings of the bones when re- 
moved; and of thu patient after tlie operation. 



Fk;. 50. 



Fic. 51. 




A second case^ very similar to tlie above as respects the 
aljsence of cause for the disease, has been recently under my 
notice, the report of it having been kindly furnished to nie 
by Dr. Garnham, of the Peninsular and Oriental Company's 
Service. The patient, aged forty, was an engineer in the 
Company's service, and enjoyed perfectly good health in the 
tropics for some years, but soon after his return to England 
his mouth became sore, sloughing of the gums took place, 
and, w^hen I first saw him, very large portions of the 
alveolus of tlie lower jaw were necrosed, and lying exposed 
in tlie mouth. Subsequently these came away or were 
removed by Dr. Garnham, and the patient having been 
reduced to an edentulous condition, as regards the lower 
jaw, it became necessary to apply to Mr. C. J. Fox, the 
dentist, for artificial aid. Dr. Garnham attributes the disease 
to depression of the vital powders, owing to long residence in 
warm climates. 

Any ulcerative affection of the mouth may lead to 
necrosis of the jaw : thus it has been met with during 
scur\'y, after cancrum oris, and after mercurial salivation. 
A very extensive sequestrum resulting from cancrum oris 
is preserved in Guy's Museum {lOOl, v.), consisting of the 
symjihysis and horizontal rami of the lower jaw, together 
with the first two molar teeth. Four years after its re- 



NECROSIS FHOM MERCURY. 119 

moval, an osseous growth was found to have taken the place 
of the original portion of the lower jaw, tlie power of mas- 
tication being good and the sense of feeling nearly perfect. 
Profuse salivation from mercury being now of rare occur- 
rence, necrosis from this cause is but seldom met with; but 
iu former years the remedy seems sometimes to have been 
worse than the disease : thus Mr. Key presented to Guy's 
Museum a sequestrum consisting of two-thirds of the 
alveolar processes of the lower jaw, the disease having been 
induced by the use of mercury for ovarian dropsy. The ex- 
foliation of the entire alveolus in the Museum of the Dublin 
College of Surgeons, already described, was also due to the 
exhibition of mercury. In the Amcriccui Medical Times of 
February 23, 1861, Dr. E. S. Cooper records the case of a 
child, aged seven, in whom necrosis invohdng the left half 
of the lower jaw, including the coronoid and condyloid pro- 
cesses, had been produced by the administration of calomel. 
After removal of the sequestrum reproduction of the jaw 
took place, the reproduced bone being at first very much 
larger than the natural bone, but gradually improving in 
shape. 

Mr. Stanley mentions (p. 72), and gives a drawing of a 
sequestrum preserved in St. Bartholomew^s Museum (I. 102), 
embracing nearly the whole body of the lower jaw, which 
suffered necrosis after the administration of a few grains of 
calomel in a case of fever. It might be doubted whether the 
necrosis was not due as much to the fever as to the calomel 
in this case, but that Mr. Stanley mentions that the patient 
had excessive salivation and severe inflammation in the gums 
and cheeks. 

The severe form of mercurial necrosis^ of which 
patients suffering from syphilis were mostly the victims in 
the days when salivation w^as looked upon as a necessary 
part of the treatment, is now practically unknown. It was 
formerly met with also as a result of the destructive ptyalism, 
produced by the fumes of liquid mercury employed in the 
manufacture of looking-glasses. When glass plates were 
converted into mirrors by sliding and compressing them 



120 NECROSIS OF THE JAWS. 

Oil to sheets of tin-foil covered with pure quicksilver, 
the men employed were liable to have their teeth drop 
out, and frequently lost portions of the jaws, their lives 
being notoriously shortened. Since the introduction of a 
chemical process by which the mercury is deposited on the 
glass, these cases of induced necrosis have become almost 
unknown. 

Syphilitic poison frequently produces necrosis of the jaws ; 
and here we find the observation of Stanley hold good as in 
other parts of the body. He says (p. 76) " Syphilis pro- 
duces its effects mostly upon the compact osseous textures, 
and in portions of bones which have thin soft coverings, as 
the flat cranial bones ;" and it is in the compact tissue of 
the palatine plate of the superior maxilla, which is thinly 
covered by mucous membrane, that we hud the ravages of 
syphilis most frequent. Occasionally the disease leads to 
necrosis of portions of the compact tissue of tlie lower jaw, 
or attacks the alveolus, or body of the upper jaw. Of this I 
have lately had two examples under my own care, one in a 
medical man, from whom I extracted a large piece of necrosed 
alveolus, and the other in a discharged soldier, aged twenty- 
three, in \A-hom also there was extensive necrosis of the 
alveolus, extending from the lateral incisor to the first 
molar on the right side. There was no question as to the 
cause of the disease in either case. In cases of extensive 
tertiary ulceration of the face also, the bones may become 
secondarily affected. 

The question of the influence of syphilis in producing 
necrosis of the alveolus, derives additional interest from 
the recent trial of an action against a dentist for damage 
due to necrosis, said to have been caused by the unskilful 
extraction of a tooth some months before. In this case one 
surgeon swore that necrosis of the jaw from syphilis was 
unknown, whilst the opposite view was strongly maintained 
by surgeons of great experience in syphilitic diseases {British 
Medical Journal, August, 1871). 

The proper local treatment of any ulceration or necrosis 
of the palate is to protect the part from contact of the 



THE USE OF OBTURATORS. 121 

tongue and food, and to close the aperture by a properly fitting 
plate of metal or vulcanite, attached to the teeth and arching 
immediately below the palate, without making pressure upon 
the edges of the hole itself. A caution may be given against 
any attempt on the part of the surgeon or patient to till 
the gap in the roof of the mouth by any form of plug fitting 
into the hole left, the eftect of which is to enlarge the aper- 
ture by absorption, so that the size of the plug has to be 
constantly increased in order to make it effectual. A pre- 
paration in St. Bartholomew's Museum shows the extent to 
which this absorption may be carried in process of years. 
The following is the description given in the Museum 
Catalogue : — 

" The base of a skull from an elderly woman^ who ap- 
peared to have been long in the habit of wearing a plug to 
close an opening in the palate. The opening gradually 
enlarging, attained such a size that nothing remains of the 
palatine portions of the superior maxillary and palate bones, 
and the alveolar border of the jaw is reduced to a very thin 
plate, without any trace of the sockets of the teeth. The 
antrum is on both sides obliterated by the apposition of its 
walls, its inner wall having probably been pushed outwards 
as the plug was enlarged to fit the enlarging aperture in 
the palate. Nearly the whole of the vomer also has been 
destroyed, and the superior ethmoidal cells are laid open. 
The plug is preserved ; it is composed of a large circular 
oork, with tape wound round it, and measures an inch and 
three-quarters in diameter, and an inch in depth. The his- 
tory of the patient is unknown. She was brought from a 
workhouse to the dissecting rooms, with the plug tightly and 
smoothly fitted in the roof of the mouth." — St. Bartholomew's 
Catalogue, 14. 

Even the employment of a piece of softened gutta-percha 
is not unattended with risk : thus, several years ago I saw, 
with Mr. Lawson, a case in which the patient had thrust a 
considerable quantity of softened gutta-percha through' an 
aperture in the palate into the nostril, where it formed a 
hard mass, which was extracted only with the greatest 



122 ■ NECROSIS OF THE JAWS. 

difficulty and at the expense of tearing one of -the 
alie. 

Phospliorus-Nccrosis. — This, which is perhaps the most 
formidable kind of necrosis of the jaw, is a disease of modern 
time, having been called into existence only since the intro- 
duction of lucifer-matches, into the inflammable material of 
which phosphorus largely enters. The earliest mention by 
British writers of disease in connexion with the manufacture 
of lucifers, appears to have been by Dr. Wilks, in the Guy's 
Hospit(d Reports of 1846-47 ; but a paragraph from a 
German author upon the subject is quoted in the Lancet of 
August 29, 1846. The notice in the Gujfs Hospital Reports 
is of a case of disease of tlie lower jaw with exfoliation, 
occurring in a lucifer-match maker ; and the remark is 
made that the disease had been noticed to be common 
among workers in lucifer manufactories — a branch of in- 
dustry which had then been introduced into Loudon some 
ten years. In Germany, however (where lucifer manufac- 
tories were started some years earlier than in England), 
phosphorus-necrosis was recognised as early as 1839 by 
Lorinser, who published a paper upon the subject in 1845, 
and was followed by Strohl, Heyfelder, Eoussel, and Gen- 
drin, and by Sedillot, in 1846. In 1847 Drs. Von Bibra and 
Geist, of Erlangen, published a work (Die Krankheiten 
der Arbeiter in den Phosphorziindholzfabriken, insbesondere 
das Leiden der Kieferknochen durch Phosphordampfe), 
which forms the basis of our present knowledge of the sub- 
ject, and the conclusions of which further experience has 
fully confirmed. 

In London the lucifer manufactories being principally at 
the East-end, cases of phosphorus-necrosis are most common 
in St. Bartholomew's, the London, and the Borough hos- 
pitals ; and their museums, especially that of St. Bartho- 
lomew's, are very rich in specimens. The medical officers 
of these institutions having thus had special opportunities of 
study, have not failed to record their experience, and refe- 
rence may be made to valuable clinical lectures upon the 



PHOSPHOJRUS-NECROSIS. 123 

subject by Mr. Simon {Lancet, 1850), Sir J. Paget {Medical 
Times and Gazette, 1862), and ]\Ir. Adams {Mediccd Times 
and Gazette, 1863) ; and to the essay on Surgical Dis- 
eases connected with the Teeth, by Mr, J. Salter {System of 
Surgery, vol. ii.). 

The cause of the disease is, uu([uestionably, the fumes of 
the phosphorus which are inhaled by the operatives during 
the process of " dipping" the matches, and in a lesser degree 
during the counting and packing them. When the disease 
first showed itself in Germany, it was tliought that it de- 
pended uj)on the admixture of arsenic with the phosphorus ; 
and it is curious that in the Museum of St. Bartholomew's 
there are some bones of cows from the neighbourhood of 
Swansea, which, under the influence of arsenical vapour, 
have become enlarged and covered with a new bone forma- 
tion closely resembling that around phosphorus-necrosis. It 
has been proved, however, that arsenic has nothing to do 
with the disease ; and if j)roof positive were wanting that 
phosphorus alone is the deleterious agent, it is supplied by 
a case quoted by Sir J. Paget, in the lecture referred to, 
of a man who induced necrosis of his jaws by inhaling 
fumes of phosphoric acid as a quack remedy for " nervous- 
ness." 

Lorinser and the earlier writers considered the disease to 
consist in blood-poisoning, the necrosis of the jaw being 
consequent thereupon, and Mr. Adams {loc. cit.) thinks that 
the theory of blood-poisoning should not be altogether dis- 
carded, since the local disease would not account for the 
constitutional symptoms experienced. This view has recently 
received the support of the eminent Berlin surgeon Yon 
Langenbeck, who maintains that all the general symptoms 
of phosphorus-poisoning are present long before the local 
disease, which he calls periostitis rather than necrosis, 
manifests itself. {Berliner Klinische Woehe7ischrift, Jan. 8th, 
1872.) The majority of surgeons agree, however, in con- 
sidering the afl'ection essentially a local one, the consti- 
tutional symptoms being only consecutive, and an interest- 



124 NECROSIS OF THE JAWS. 

iug account of the post-mortem examination of a case of 
general poisoning by phosphorus, following necrosis of the 
jaw, will be found in the Patliolofjiccd Society's Transactions 
for 1869. 

It is found that the phosphorus fumes produce no inju- 
rious effects so long as the teeth and gums of the workers 
are sound, but as soon as the teeth become carious, or if a 
tooth is extracted so as to leave an open socket, the disease 
rapidly develops itself. The experiments upon animals, by 
Geist and Von Bibra, are amply confirmatory of this view, 
since they found that rabbits exposed to phosphoric fumes 
suffered no injury so long as the teeth and jaws were unin- 
jured, but that if the teeth were extracted or the jaw broken 
periostitis and necrosis rapidly resulted. On the other 
hand, it may be mentioned that a case has been recorded by 
Grandidiev (Journal filr Xinderkrankheitcn, 1861), of necrosis 
of the upper jaw from phosphorus fumes in a child but six 
weeks old, and in whom therefore the teeth were not de- 
veloped, and Langenbeck is opposed to the notion that 
carious teeth predispose to the disorder. 

The liability of the two jaws to the disease appears to be 
about the same, or perhaps with a slight preponderance in 
favour of the lower jaw. Of 52 cases given by German 
authorities, 21 were of the superior maxilla, 25 of tiie in- 
ferior maxilla ; in 5 both jaws were involved, and one case 
is uncertain. (British and Foreign Mcdico-Chirurgical 
Bcviciv, April, 1848.) Mr. Salter (loc. eit.) says, " In five 
cases which I have witnessed, the lower jaw was diseased 
in four, and the upper in one ; whereas four which occurred 
in the practice of a surgical friend, were confined to the 
upper jaw. In seventeen instances of which I have obtained 
particulars or seen specimens, nine were connected with the 
supeiior, and eight with tlie inferior maxilla. The disease 
is therefore pretty evenly balanced between the two 
jaws." The St. Bartholomew's Hospital Museum contains 
excellent specimens of both jaws affected by this form of 
disease. 

The Sijmptoms of Necrosis of the jaws, from whatever 



SYMPTOMS OF NECROSIS. 125 

cause, are much the same, but as they present themselves 
in the most marked degree in phosphorus-necrosis, it will be 
convenient to describe them under this head. 

Pain referred to the teeth is one of the earliest symp- 
toms of the disease, and this, which was intermittent at first, 
becomes at length continuous. The teeth become loose, 
and pus is seen to exude from their sockets. At the same 
time the gums become swollen and tender, and are detached 
to a greater or lesser degree from the alveoli, giving constant 
exit to a purulent discharge. In all cases of necrosis the 
face is swollen, so that, if only one side of the jaw is affected, 
a peculiar lo]D-sided effect is produced. In the cases of 
phosphorus-necrosis, however, the swelling of the face is 
much more marked, the soft tissues around the bone being 
infiltrated and puffy to an extent which is not witnessed in 
other forms of the disease. One or more openings now form 
externally, through wliich pus constantly exudes, and the 
probe introduced through these, readily reaches bare and 
dead bone. 

The patient^s general healtli has by this time become 
seriously affected, owing both to the actual suffering he has 
undergone, and to the interference with his nutrition which 
the state of his mouth necessarily involves ; it being im- 
possible for him to take any but fluid or semi-fluid food, 
and that in small quantities. The constant presence of 
most offensive discharges in the mouth, and mixing with the 
food, must have an injurious effect upon the patient, though 
this is questioned by Salter, who remarks that these j)atients 
swallow daily many ounces of pus " without any obvious 
detriment to health." The necrosed portions of bone pro- 
ject more or less into the mouth, and give the patient great 
inconvenience, and in very severe cases of phosphorus-necro- 
sis gangrene of the cheeks and lips ensues, with a rapidly 
fatal termination. In less severe cases, the patient may 
drag on a wretched existence for months, and sink at last 
from exhaustion, or may occasionally recover with consider- 
able loss of bone and deformity. 

Advanced necrosis of the upper jaw may lead to exten- 



12(3 NECROSIS OK THE JAWS. 

sion of mischief to the Lrain M'itli a fatal result, as I have 
myself seen on one occasion. The patient was a young 
woman, aged twenty-three, in wlioui necrosis of tlie upper 
jaw had existed for nine months, when head symptoms 
supervened, and she rapidly sank and died comatose. At 
the post-mortem examination, I found an abscess in the 
anterior lobe of the cerebrum, evidently originating from the 
ethmoid bone, the cribriform plate of which was necrosed 
and perforated. 



127 



CHAPTEK IX. 

EEPAIR AFTER NECROSIS TREATMENT OF NECROSIS. 

It has been already remarked under the head of Exanthe- 
matous Xecrosis, that in young subjects a development of 
fibrous tissue takes place after loss of substance in the upper 
jaw. This is not the case when loss of part of the superior 
maxilla takes place in adult life, except in rare instances, it 
being remarkable that the periosteum of the upper jaw 
ordinarily makes no effort at repairing, by effusion, the 
mischief whicli has taken place. M. Oilier, of Lyons, in 
his A'ery valual)le work " La Regeneration des Os," (1867) 
gives a case of phosphorus-necrosis of the upper jaws 
wliere a certain amount of new bone was produced, and also 
one of necrosis of the upper jaw from other causes, in wliich 
a development of osteo-fibrous tissue took place in a young 
woman of nineteen. He quotes also from the practice of 
lUllroth, of Zurich^ the case of a man, aged twenty-seven, in 
whom, after phosphorus-necrosis, a development of plates of 
bone took place. These cases must be regarded, however, 
as quite exceptional, Tri'lat in his thesis (1857), having failed 
to discover a case of osseous reproduction of the superior 
maxilla. In the lower jaw, however, tlie case is very dif- 
ferent, tlie periosteum and the surrounding tissues being 
very active in producing new bone, to take the place even- 
tually of that which is necrosed. 

So soon as the periosteum is separated from the jaw 
by the formation of pus around the sequestrum, it appears 
to take on an active condition which leads to the effu- 
sion of plastic lymph. This becomes rapidly converted 
into fibro-cartilage and then into bone, which forms a 
more or less complete shell around the necrosed portion. 
Through the cloaccv, or openings in this new shell of bone, 



128 REPAIR AFTER NECROSIS. 

which correspond to the external apertures on the skin, 
and also from the mouth, the dead bone or sequestriLm can 
he readily examined with the probe, and, when sufficiently 
detached and loosened to be readily extracted, it should be 
removed if possible through the mouth so as to avoid de- 
formity from an external wound. It is of importance that 
this removal should not be undertaken until the shell of 
new bone is sufficiently organized to maintain the shape of 
the original bone, for if otherwise, the reproduction of the 
bone will be interfered with, and perhaps prevented. So 
soon as the sequestnmi is removed from the interior of the 
shell of new bone, the space thus left becomes rapidly filled 
with granulations springing up from the whole surface of 
the cavity, and these are soon converted into a fibrous mass 
which is ultimately developed into bone. In 1869 I had 
under my care in University College Hospital a case of 
necrosis of nearly the entire lower jaw in a man of twenty- 
two, from whose mouth I extracted several large sequestra, 
including the right condyle. In this case, and in others of 
the kind which I have seen, the repair has been of the most 
perfect kind, the movements of the jaw being as free as if 
the articulation had not been interfered with. The details of 
the case will be found in the Appendix (Case YI.). 

In the Medico- Chirurgical Trans., vol. Ivii., is a case of 
phosphorus-necrosis, reported by Mr. Savory, in which, six 
months before the death of the patient, a lad of eighteen, 
the whole of the lower jaw was extracted, and is preserved 
in St. Bartholomew's Museum (I. 232). Although " at this 
time there was not sufficient firmness in any part of the 
region to indicate the formation of new bone, yet in the 
course of a week or two afterwards there was distinct evi- 
dence of new bone on either side about the angle, which 
gradually extended." The new lower jaw which had been 
formed is shown in fig. 52, and is perhaps one of the most 
perfect specimens of the kind ever seen. " In size, shape, 
and development it is very remarkable. The bone is solid 
and dense and in two pieces onl}^ The greater portion 
constitutes the whole of the bone, with the exception of the 



REPAIR AFTER NECROSIS. 



129 




130 REPAIR AFTER NECROSIS, 

right ramus. This was united to tlie body by fibrous tissue, 
and separated during maceration. In size and form, and 
especially in the absence of alveolar portions, the jaw very 
nearly resembles the edentulous maxilla of a very old person, 
as shown in fig. 53. 

In the St. Bartholomnvs Hospital Reports, vol. i. (1865), 
a very remarkable case of restoration of the lower jaw is 
described by Mr. Thomas Smith, to whom I was indebted 
for the original drawing of the preparations in the hospital 
museum which accompanied this essay. The case was one 
of necrosis of the entire lower jaw in a lucifer-match maker, 
but Twt presenting the peculiar pathological condition of 
pumice-stone deposit upon the sequestrum, which is charac- 
teristic of the phosphorus disease and will be afterwards re- 
ferred to. Mr. Smith removed the sequestrum of the entire 
jaw in two pieces (St. Bartholomew's Museum, I. 233), and 
the patient went out of the hospital at tlie end of six weeks, 
but died suddenly the next day. 

Tlie following is Mr. Smith's description of the' repair : — 
" The new bone was situated in front of and on a lower 
plane than the bone it replaced ; it was distinctly embedded 
in the soft parts between the anterior layer of the peri- 
osteum of the old jaw and the integuments of the face. 
The relative position of the old and new bone is shown in 
the drawing. On the posterior aspect, some of the fibrous 
texture of the gum has been left so as to show a groove in 
the soft parts, which was originally occupied by the dead bone. 
This groove had very greatly diminished in size before the 
patient's death, and has still further shrunk by maceration 
in spirit. 

The temporal muscle was found attached to the coronoid 
process ; the masseters were blended with the outer surface 
of the angle and ramus of each side ; while, behind the sym- 
physis, there may still be seen in the specimen the remains 
of the genio-hyoid, genio-hyoglossi, and digastrici. Xo other 
muscles were found attached to the bone. The inferior 
dental nerves were found lying in tlie fibrous texture of the 
old gum. There is apparently no provision for them in the 



SPECIMEN OF REPAIR. 131 

new jaw, from whicli they lay quite separated by both layers 
of the periosteum of the necrosed jaw. 

The new bone consisted chiefly of three portions, of which 
two are formed by the coronoid process and condyle together, 
of either side ; whilst the third and largest portion repre- 
sents the right ascending ramus, the angle, horizontal ramus, 
and symphysis, and extends as far as tlie position of the 
eye-tooth on the left side. The part of the jaw that is 
wholly deficient in bony structure is included between tlie 
position of the eye-tooth and last molar of the left side. The 
parts in which most bone is found being apparently those 
points where ossification commenced, on the coronoid pro- 
cesses, the angles, and especially the neighbourhood of the 
symphysis, where the bone is more abundant, denser in its 
structure, and more perfectly formed than elsewhere. 

The newly-formed jaw, on microscopic examination, shows 
all degrees of development, from a finely fibro-nuclear 
matrix up to perfect bone. The bone differs from ordinary 
compact bone in being excessively vascular, the Haversian 
canals being very large, near together, freely anastomosing, 
and here and there in their wall j^resenting fusiform and 
pouch-like dilatations, in fact, resembling in their outlines 
veins slightly varicose. 

The bone is thickly studded with lacuna?, and these are 
peculiar in being very large in their cavities, less uniform in 
their general outline, and bearing fewer canaliculi than is 
usual in well-formed bone. In the newest parts of the bone 
the lacunae are merely irregularly formed cavities without 
distinct canaliculi. 

From the relation of the dead bone to the soft parts, 
lying as it did in a fossa formed by the gaping gums, from 
the relation of this fossa to the new bone, as seen in the 
specimen, it is evident that the regeneration of bone in this 
case did not take place from the osseous surface of the peri- 
osteum, but rather from the fibrous structure of the gum in 
front of the original jaw. The only portion of bone in this 
case formed directly from the detached periosteum, was re- 
moved at the time of the operation, and may be seen in the 

K 2 



132 REPAIR AFTER NECROSIS. 

necrosed jaw adhering to the raunis and angle of the left 
side. It formed no part of that system of bone formation 
which eventually reproduced the jaw." 

This case is remarkable in more ways tlian one. In the 
first place, the absence of the pumice-like deposit upon the 
sequestrum would appear to exclude it from the category of 
phosphorus-necrosis, but the patient was undouLtedly ex- 
posed to the action of phosphorus, and it will be shown at a 
later period that this deposit is not of necessity connected 
with phosphorus. The second notable point is, that according 
to Mr. Smith's description the reparative material was formed 
not around, but entirely in front of or below the sequestrum. 
The third point, still more remarkable, is, that if Mr. Smith's 
observation is correct, the new structure was entirely oiUside 
the periosteum of the jaw, and was derived entirely from the 
surrounding soft parts. 

Mr. Smith is too accurate an observer to have been de- 
ceived by the appearances, and we must conclude, therefore, 
that not only was the bone killed by the action of the poison, 
but that the periosteum also lost its vitality to such an ex- 
tent that it was unable to secrete that pumice-like bone 
usually found in these cases, or to assist in any way to form 
reparative material. That the surrounding soft parts shoidd 
under these circumstances have assumed the reparative func- 
tion to the extent they did, is a remarkable instance of the 
adapting powers of Nature. 

In conmienting upon the above case, ]\Ir. Smith expresses 
an opinion that " of late the office of the periosteum as an 
osteogenetic membrane has been much magnified at the ex- 
pense and to the disparagement of other sources of bone re- 
production." M. Oilier, on the other hand^ whose physio- 
logical researches on the nature of periosteum are well 
known, in his work already alluded to, strongly maintains the 
bone-producing power of the periosteum and advises its pre- 
servation where possible ; giving cases wdiere this has been 
followed by the reproduction of bone, as has been frequently 
witnessed in England. The question of the so-called sub- 



RETENTION OF THE TEETH. 133 

periosteal resection will be discussed under the head of 
Treatment of Necrosis. 

Whatever the tissue from which the bone is reproduced, 
there can be no question as to the fact of its reproduction 
in the majority of instances of necrosis of the lower jaw. 
Even when, as in my own case already mentioned, the condyle 
with a large portion of the ramus of the jaw is necrosed, 
complete repair has been found in young subjects. Stanley, 
however, quotes a case of this kind from Desault, as one 
" of the least frequent examples of the reproduction of bone 
consequent on necrosis," and refers to one recorded by Mr. 
Syme. As additional examples may be quoted one by the 
late Mr. H. Gray {Pathological Transactions, vol. ii.), 
wliicli occurred in the practice of Mr. Keate, and one by Dr. 
Cooper, of San Francisco, which has been already referred 
to. A case of sub-periosteal resection of one half of the jaw 
by M. Maisonneuve, in which complete repair took place, 
will be referred to further on. On the other hand it should 
be remarked that several instances of non-repair of lost 
bone have been recorded. Thus Stanley mentions a case 
under the care of Mr. Perry, which will be referred to again, 
in which no repair took place ; and three similar cases are 
to be found in South's Chelius. Also in the Lancet, 25 th 
January, 1862, it is mentioned that a patient from whom 
Mr. T. Wakley removed an extensive necrosis in 1857, was 
at that time to be seen about the streets exhibiting himself 
for a livelihood, and everting his mouth to show that his 
lower jaw was absent. 

A remarkable feature in Mr, Perry's case, already men- 
tioned, was, that though the entire jaw was necrosed and 
removed, yet " nearly all the teeth remained in the mouth, 
and were kept together by their connexion with the gum ;" 
and according to Mr. Stanley, the patient " chewed her food 
by a movement of the upper jaw (?), aided by the action of 
the tongue in rubbing the morsel against the teeth." Ex- 
traordinary as it appears, that the teeth should thus remain 
■in situ, the fact is undoubted, and is confirmed by other 
examples : thus, Mr. Sharp, of Bradford {Medico-Chirurgical 



134 REPAIR AFTER NECROSIS. 

Transactions, vol. xxvii.), removed a large sequestrum from a 
young woman, aged twenty, through an incision beneath the 
chin, and all the teetli remained firm. In the Medical Times 
and Gazette of October 30th, 1858, also, it is mentioned that 
Mr. Skey brought before the students of St. Bartholomew's 
a young man of twenty, from whom, four months before, he 
had removed a sequestrum including the entire left side of 
the jaw from the ramus to the symphysis, and the right side 
as far as the last molar tooth. The sequestrum showed the 
sockets of twelve teeth — viz., all those of the left side, and the 
incisors, canine, and first bicuspid of the right side ; but tlic 
whole of the alveolar border of the right side was not pre- 
sent in the sequestrum. Instead of coming away with the 
bone, the incisors, canine, and first bicuspid of the right side, 
and even the left central incisor had remained in the gum. 
The patient now applied to Mr. Skey to have these teeth 
removed, as, although they evidently ])ossessed vitality and 
were firmly attached to the gums, they had sunk in position 
so as to be irregular and inconvenient. I have, however, 
seen one case in which the teeth remained firm and useful 
after extensive necrosis ; but in this case the sequestrum in- 
volved only the outer plate of the jaw, the inner with a 
great part of each socket being left for the support of the 
fangs of the teeth. 

An observation of Llr. Salter's {System of Surgery, vol. 
ii.) deserves notice, and it received confirmation from one 
of the cases recorded by JMr. Chalk in the paper already 
referred to. He says, " Though it has not been stated in 
books, this repair of the lower jaw is but temporary, for 
after a time — often a considerable time — the new bone 
diminishes by absorption to a mere arch, and ultimately there 
is scarcely enougii bone to keep out the lower lii^, and the 
chin is utterly lost. I have had an opjjortunity of examin- 
ing this state of parts after the lower jaw had been removed 
ten years. How far this loss, by absorption of supplemental 
bone, may be prevented by supplying it with a function 
through the means of artificial teeth, is a question of theo- 
retical interest and of practical imj^ortance." 



THE PUMICE- LIKE DEPOSIT. 135 

One, almost constant^ pathological peculiarity in cases of 
phosphorus-necrosis has-been already alluded to, and deserves 
special notice ; it is the deposit of a peculiar, pumice-like, 
bony material around the necrosed portions of the lower 
jaw, for it is not found in cases of disease of the upper jaw. 
This is doubtless derived from the periosteum, although so 
closely adherent to the sequestrum as to be invariably 
brought away with it ; and though resembling true bone in 
some particulars, it is decidedly of a lower development. 

According to Von Bibra {op. cit), who has laboriously 
investigated the subject microscopically, the Haversian 
canals exhibit in part a larger diameter than those of normal 
bone and are empty, except where the deposit appears 
smooth and compact, and is partially covered with periosteum. 
They are iwt i)aralld with the general direction of the bone, 
but are placed at right angles to the latter ; they interlace 
with one another, sometimes expanding to form sacs, some- 
times contracting, and end with open mouths on the surface. 
Their mouths are more minute in the most recent deposit, 
and appear larger in older layers. The bone corpuscles 
are rounded off or angular, and their circumference is less 
decided ; during the progress of the formation of the deposit 
they are very large, and their contour proportionably unde- 
fined. They appear filled and dark- coloured ; at first they 
are lighter and they have ramifications like those of normal 
bone, which increase in number with the age of the deposit. 
The fundamental structure of the deposit is laminated, and 
several layers are distinctly seen resting upon one another. 
It exhibits rents with which the ramifications of the cor- 
puscles are connected, and which may therefore be con- 
sidered as continuations of the latter. Spots are also visible 
here and there, which Von Bibra looks upon as accumula- 
tions of earthy matter. This matrix of the new deposit is 
at first very brittle ; after the deposit has been exposed to 
the process of absorption it shows a powdery appearance, as 
if sprinkled with a coarse powder. 

This description of the microscopic appearances may be 
advantageously contrasted with that of the new bone in 



136 REPAIR AFTER NECROSIS. 

Mr. T. Smith's case of restoration of the jaw (p. 131), of 
which the Haversian canals were parallel to those of the ori- 
ginal bone instead of being at right angles to them, which 
is such a marked peculiarity of the pumice-like deposit. 

It appears, however, that cases of necrosis other than 
those due to phosphorus occasionally lead to a deposit of 
pumice-like bone upon the sec|uestrum. Mr. Perry's case 
of necrosis of the entire lower jaw, already alluded to (and 
which will be found in ex-temo in the Mcdico-Chirurgi-xd 
Transactions, vol. xxi.), is a case in point, the sequestrum, 
as may be seen from the drawing given of the prepa- 
ration in St. Bartholomew's Museum, being thickly en- 
crusted with new bone, closely resembling that seen in 
phosphorus cases. The disease in this case was attributed to 
rheumatism, and corresponds very closely to the description 
given by Dr. Senftleben of the later stages of acute rheu- 
matic periostitis, (See p. 108.) He says, " Spontaneous 
separation of the sequestrum rarely ensues ; it remains to 
some extent in organic connection with the osteophytes, and 
ultimately, after a number of months, a year, or even more, 
an operation has to be performed, in which both the seques- 
trum and the osteophytes are removed together." So far as 
I am aware, the new bone in Mr. Perry's case has not been 
submitted to microscopic examination. 

A preparation in the College of Surgeons Museum (1412) 
bears upon this question. It is a portion of the lower jaw of 
a girl let. ten, consisting of the condyle and part of tlie ramus 
and the coronoid process (separate), for which I was in- 
debted to Mr. Lawson. The symptoms were those of ne- 
crosis, there being abscess, &c. ; and in December, 1866, that 
gentleman cut down upon the seat of the disease and re- 
moved those portions wliicli were separated from the rest of 
tlie bone. The })reparation shows the ramus of tlie jaw at 
the lower part of normal thickness and apparently necrosed, 
but at tlie upper part there is around it a deposit of new 
1)one, very closely resembling the pumice-stone deposit of 
})hosphorus-necrosis. A portion of tliis has been detached, 
but it may be observed that the articular cartilage is perfect. 



TKEATMENT OF jSEOROSIS. 137 

and the periosteum near it healthy, although, owing to the 
new deposit, the condyle and neck of the jaw are greatly 
altered in shape. This appears to me to have been a case 
of Ostitis rather than Periostitis^ the deposit resembling 
that found under such circumstances ; and the fact of the de- 
posit taking place beneath the apparently healthy periosteum, 
would appear to point to the same solution of the question. 

Treatment of Mcrosiiy. — In the early intiammatory stage 
of the disease, it is obviously of the first importance to get 
rid of any local cause which may be exciting or keeping 
up irritation, and therefore any diseased teeth or stumps 
should be immediately extracted, and the patient should 
be removed from the action of any local irritant, such as 
the fumes of phosphorus. Local abstraction of blood by 
leeches, both externally and internally, and by scarifica- 
tion of the gums, will relieve the congestion ; and the 
application of emollient poultices externally, and of poppy 
fomentations in the mouth, will relieve the pain. The 
bowels having been cleared, iodide of potassium should be 
had recourse to in full doses, according to the age of the 
patient, combined with opium if there is much pain and 
restlessness. 

By these means the disease may be prevented from pro- 
ceeding beyond the stage of periostitis, but if from the 
swelling of the parts about the jaw it is to be feared that 
the destruction of the bone is probable, free incisions should 
be made within the mouth down to the bone, to give exit to 
effusion, and thus, if possible, avert the death of the bone, 
after which the treatment above recommended should be 
pursued with assiduity. When necrosis has actually taken 
place, and pus has formed around the jaw, its tendency to 
the surface is so great that, if free exit for it is not made 
within the mouth, it will cause sinuses externally, and gixe 
rise to great disfigurement. Free incisions should therefore 
be made through the gums, but without disturbing the efforts 
at repair if they are already in progress. As all hope of 
arresting the disease must now be abandoned, it is useless 
to continue the administration of drugs except as general 



138 TREATMENT OF NECROSIS. 

tonics, and at the same time every effort must be made to 
support the patient's strength by suitable diet. Since it is 
impossible that the patient should masticate solid food, it 
is important that animal food should be prepared in a 
suitable manner, and this may be attained by making use 
of soups or essences of meat, and by reducing well-cooked 
meat to a mash with pestle and mortar. Milk and eggs 
form very suitable articles of food, and must be supplemented 
with wine or, better, stout. 

The offensive discharges constantly present in the mouth 
must be combated wdtli detergent gargles of chlorinated 
soda or permanganate of potash, and when the patient is 
unable to cleanse his mouth satisfactorily by his own efforts, 
it should be mopped out with small sponges affixed to a 
handle, assisted by the use of a syringe. 

Most British surgeons agree in counselling non-inter- 
ference with the sequestra in cases of necrosis until the 
shell of new bone around is sufficiently developed to main- 
tain the form of the jaw ; they are then to be extracted 
through the mouth, if possible, and if not, through incisions, 
placed so as to cause as little subsequent deformity as 
possible. When the sequestrum, although partially de- 
tached, is not ready for removal, and greatly inconveniences 
the patient, a part may be clipped off with the bone forceps, 
so as to present a smooth surface, and if the teeth are loose 
and troublesome they had better be removed at once, but if 
firm they should be left, since, as has been shown, they 
occasionally become useful. The caution already given 
against interfering with the permanent set of teeth in cases 
of necrosis in children should be borne in mind. 

Some continental surgeons, however, interfere at any 
early date, and among them Professor Billroth, who, accord- 
ing to the report of the meeting of the Medical Congress at 
Zurich in 1861 {Medical Times and Gazette, June 8, 1861), 
" penetrates immediately, with one incision, which he makes 
parallel to the necrotic part, tlirough the skin down to the 
bone ; he then scrapes oti' the periosteum with its bony 
layers upwards and downwards, by means of a raspatorium. 



SUB- PERIOSTEAL RESECTION. 139 

and saws smaller or larger pieces of bone out of tlie jaw ; 
or lie nips those pieces oft' by means of bone-pincers. In 
a few cases it appeared advisable to disarticulate at once 
one or both coronoid and condyloid processes of the lower 
jaw, which was very easily done, as the joint had become 
very loose in consequence of the long suppuration. Of the 
six cases shown by the Professor, two were healed, and 
amongst them was one of total resection of the jaw in a 
woman of thirty-five years. This case was in so far re- 
markable, as two apparently healthy teeth had remained in 
the periosteum, which had become partly ossified, and in the 
gums, which had remained healthy ; and these have now 
been used for seven months. Mastication is not impaired, 
and the woman has a much healthier appearance. The 
second case in which the resection of one-lialf of the jaw 
was performed, is also well healed ; but the mouth is, of 
course, crooked. Two cases, in which a partial resection has 
been made, are progressing favourably ; in another case the 
treatment with mercury and iodine has been commenced." 

When the whole lower jaw is necrosed it is necessary to 
divide it before it can be extracted. This may be done, as 
in Mr. Perry's case, by making a section with the saw near 
the angle on each side, or, better, by dividing with the saw 
at the symphysis, either without external incision, as in Mr. 
T. Smith's case, or after reflecting flaps of skin, as in a case 
of Sir J. Paget's, which will be found in the Lancet, 1862. In 
a case of necrosis of the entire lower jaw, from phosphorus, 
which was in the London Hospital under Mr. Adams' care, 
that gentleman preferred to divide the symphysis with a 
mallet and chisel, and the case is moreover remarkable from 
the unusual occurrence of secondary hcemorrhage, for which 
ligature of the common carotid became necessary — the 
patient eventually recovering. The case will be found in 
detail in the Medical Times and Gazette, 1863. 

Under tlie name of " Sub-periosteal Picsection," operations 
have been described by foreign surgeons, which in no re- 
spect differ from the extraction of sequestra as ordinarily 
practised, and of which the following case, taken from the 



140 TREATMENT UF NECROSIS. 

Lancet, of 1863, is a good example : — " M. Piizzoli, of 
Bologna, submitted to the Surgical Society of Paris a case 
of necrosis of the lower jaw, from the fumes of phosphorus, 
in a man aged fifty-six years, in which the sequestra were 
removed through the mouth. M. Eizzoli made incisions on 
either side of the gums, scraped the tliickeued periosteum 
with a spatula from the dead bone, and removed the latter 
piecemeal. The preserved periosteum generated new bone 
in the place of the portions taken away, which comprised 
the body and part of the ramus on each side. It was, how- 
ever, soon found that the upper part of the ramus and the 
condyle were also diseased ; these portions of bone were also 
removed through the mouth with the same precautions, and 
the ]:)eiiosteum again acted in the same way. Eventually 
tlie man Avas able to use his jaw, and masticate, though de- 
prived of teeth. M. Forget, who reported on the case, 
observed, very justly, that there was nothing new in the 
action of the periosteum in necrosis of bones, surgeons liaviug 
long acted upon this periosteal property in such cases. M. 
Flourens had pointedly said, ' Take away the bone, preserve 
the periosteum, and the preserved periosteum will restore the 
bone ;' l;ut this applies less to cases of necrosis of bone than 
to cases of experiments on animals and operations performed 
on healthy bone and periosteum. And even in these cases 
it should be remembered that osseous substance is reproduced, 
but not the actual bone as it existed before the resection." 
In some cases, however, incisions have been made at a com- 
paratively early stage, before the shell of new bone has been 
formed, and the sequestrum immediately extracted, with 
good results. It may be doubted, however, whether there 
is any real gain in such procedures, either in time or residt, 
since the repair is no more rapid than if the sequestrum 
were left, and there is the additional risk both of the actual 
operation, and of the deformity which may result from the 
premature withdrawal of the sequestrum. A case from the 
practice of M. ]\Iaisonneuve, illustrating the practice in 
tlie lower jaw, will be found in tlie Comptes Ilcndus, April, 
1861. In his standard work, " La Regeneration des Os," 



PREVENTION OF PHOSPHORUS-NECROSIS. 141 

M. Oilier, of Lyons, gives two cases of subperiosteal re- 
section, one of the upper and one of the lower jaw, for 
necrosis, in neither of which was there any osseous develop- 
ment ; and these cannot, therefore, be regarded as very 
satisfactory examples of a proceeding whose great aim is the 
development of new bone. 

With regard to the prevention of phosphorus-necrosis, the 
following extract from Mr. Simon's report to the Privy 
Council (1863), may be quoted with advantage, as giving 
the results of Dr. Bristowe's careful investigation of the 
subject : — " The dangers to which I have adverted, as 
belonging to the phosphorus industry, belong exclusively to 
working with common phosphorus. Working with amor- 
phous phosphorus is unattended with danger to health. 
Since, howe^'er, it appears that, with reasonable precautions, 
the use of common phosphorus for match-making need not 
be an unwholesome occupation, I cannot say that, in my 
opinion, the substitution of amorphous for common phos- 
phorus in the manufacture is, for sanitary purposes, an object 
to be unconditionally insisted on. Yet having regard to the 
fact that amorphous phospliorus not only is manufactured 
without danger to the worker, but that its use in lucifer 
boxes also involves infinitely less danger of fire than belongs 
to common lucifer matches, I think that the substitution is 
altogether one to be desired. And, of course, witli reference 
to any restriction which tlie legislature might think of im- 
posing on the utilization of common phosphorus, it would 
deserve to be remembered that manufacturers would have at 
their oj)tion the alternative of using, without restriction, the 
innocuous amorphous material." 



142 



ClIAPTEE X. 

inTEROSTOSIS. 

UxDEii the head of difiused hyperostosis it will be con- 
venient to group together those remarkable examples of 
hypertrophy of the maxilla?, and more or less of other bones 
of the face and cranium, which have occurred from time to 
time, and have been recorded b}' Howship, Griiber, Astley 
Cooper, Bickersteth, and others. 0. Weber regards the dis- 
ease as the result of erysipelas, and compares it, in its results, 
to elephantiasis of the soft structures ; while Virchow has 
o'iven it the name of " leontiasis ossea." 

Mr. Howship's case is recorded in that gentleman's 
" Practical Observations in Surgery" (1816). The patient, 
when aljout forty-five years of age, and apparently in per- 
fect health, was exposed to a cold wind, immediately after 
which he perceived an itching and heat in liis eyes, and 
swelling of the face rapidly supervened. A small tumour 
formed just below the inner angle of each eye, which burst, 
and, after twelve weeks, he was able to resume his employ- 
ment. He suffered from inflammatory attacks in the 
tumours, with much pain in the head, on more than one 
occasion, and consulted many medical men, but no treat- 
ment relieved the disease or retarded the growtli of the 
tumours, which increased slowly, and were of stony hard- 
ness. The eyes were projected from the orbits by the 
tumours, and the right eye inflamed and burst, ^vhile the 
left was accidentally ruptured by a blow. The patient 
lived to over sixty years of age, and died of apoplexy, having 
been occasionally maniacal during the last two years of his 
life. The accompanying portrait (fig. 54) is taken from 



MR HOWSHIP'S CASE. 143 

Mr. Howsliip's work. The skull of this patient is preserved 
in the College of Surgeons (1608), and shows, as might 
be anticipated from the portrait, two large masses of almost 
exactly symmetrical form and arrangement, which have 
partially coalesced in the median line. The growths are 
as hard as ivory, and consist of a very close cancellous 
structure. They project more than three inches in front 
of the face, and "an inch beyond the malar bones on each 

Fia. 54. 




side ; they completely fill l)oth orbits, the cavities of tlie 
nose, and, probal)ly, botli antra, and they extend as far 
backwards as the pterygoid plates of the sphenoid bone. In 
the Catalogue of the Museum it is stated that the man 
attributed the growths to repeated blows received on the 
face in fighting, but Mr. Howship makes no mention of 
this, and the information was probably derived from Mr. 
Langstaff, in whose collection the preparation originally 
was. 

A skull of a Peruvian^ also in the Museum of the College 
of Surgeons (1238), exhibits the same form of disease, but 
of a more diffused character, all the bones of the face, as 
well as the frontal and the adjacent parts of the sphenoidal 
and parietal bones, being enlarged and thickened in a re- 



144 HYPEROSTOSIS OF THE JAWS. 

inarkable mauner. The nasal fossa' and orlilts are nearly 
closed, the superior maxillary bones, and the orl^ital portions 
of the malar and frontal bones, having grown into great 
knobbed and tubercular masses, in whicli their original form 
can be hardly discerned. The hard palate is similarly 
diseased. The lower jaw is enormously enlarged at its 
right angle, and in the greater jDart of its right half it 
measures upwards of five inches in circumference, and all 
but three of its alveoli are closed up. A section of the 
lower jaw sliows that its interior is composed of an almost 
uniformly hard and comj>act, but finely ])orous, bono. There 
is no liistory attached to the specimen. 

Sir Astley Cooper's patient was a Billingsgate fisli-woman, 
long remarkable for her hideous appearance, who died of 
apoplexy in St. Thomas's Hospital, in the museum of ^^hicll 
institution the skull is preserved. (C. 195.) In connexion 
with each superior maxilla is a rounded bony growth, ex- 
tending from the lower margin of the orbit to the roots 
of the alveolar processes. The cavity of each antrum is 
occupied by the growth, which by its projection has en- 
croached upon the nasal fossie, and filled the frontal and 
ethmoidal sinuses. The case, therefore, closely resembles 
Mr. Howship's specimen. 

Mr. Bickersteth's very remarkable specimen was exhi- 
bited to the Pathological Society of London in April, 1866, 
by Dr. JMurchison, and its description in the Society's Trans- 
actions is illustrated with admirable lithographic drawings. 

The patient, who died at the age of thirty-four, first 
noticed an enlargement of the bones of the face when a boy 
of fourteen. Tlie swelling of the face gradually increased, 
and thirteen years after its commencement a similar hard 
swelling appeared along the course of the left fibula. About 
two years before death he began to suffer severe pain, which 
continued to his death, this being the result of emaciation, 
consequent upon the encroachment of the disease upon the 
mouth. All the bones of the head are more or less involved 
in the disease, with the remarkable exception of the occipital 
bone. The malar bones are developed into dense globidar 



bickersteth's case. 145 

masses, the size of an orange. The palatal j)rocesses of the 
superior maxillae are also greatly diseased, a rounded mass 
projecting down on each side so as to fill up the cavity of 
the hard palate to a level with the alveolar ridge. The 
lower jaw is enormously thickened in every direction, the 
right side more so than the left. Little trace can be seen 
of a condyle, coronoid process, or sigmoid notch, tlie whole 
being fused into one uniform globular mass. 

A very elaborate account of the specimen, witli measure- 
ments and microscopical appearances by Mr. De Morgan, 
will be found in the 17th vol. of the Pathological Sodctj/s 
Transactions, from which the above is condensed. 

A fourth specimen is preserved in the Musee Dupuy- 
tren, in which both upper and lower jaws are extensively 
affected, and specimens showing the disease in a lesser degree 
will be found in the museum of the Dental Hospital, 
Leicester Square, and elsewhere. 

In all these specimens the external surface of the bones 
affected is more or less coarsely tuberculated ; the tissue is 
hard and dense, and minutely perforated for the passage of 
bloodvessels. In the case of the lower jaw of the Peruvian 
skull, the interior is composed of an almost uniformly hard 
and compact, but finely porous bone. Traces of tlie original 
walls of the jaw are discernible nearly an inch beneath the 
surface of the most enlarged part, but its interior is filled up 
with the same kind of osseous substance as that which is 
outside the trace of the wall. 

A microscopical examination of the St. Thomas's Hospital 
specimen " shows it to consist of two kinds of bony matter ; 
one firm and compact, while the other is more or less soft 
and spongy. In the former. Haversian canals occur, having 
concentric lamina? around them, but in the spongy portion 
cancelli only are present, and the bone exhibits a granular 
structure, with numerous bony cells arranged in no definite 
order." 

In Mr. Bickersteth's specimen, " The compact structure 
is traversed in every direction by large branching and com- 
municating vascular canals, forming in some places a close 

L 



146 HYPEROSTOSIS OF THE JAW:S. 

network The spaces between the canals are tilled 

np by bone-tissne of ordinary character. The lacuna3 are in 
general very numerous, but they are small, and for the most 
part elongated. Very few traces of true Haversian systems 
are to be seen." 

It is stated in the report upon the last specimen, that the 
microscopical appearances are nearly identical with those of 
the Peruvian skull ia the Hunterian Museum. 

The disease appears to consist primarily in some inllam- 
matory aflection of the periosteum, which leads to the de- 
posit of new bone, and the exj)ansion and filling up of the 
original osseous structure. It appears to be entirely un- 
connected wdth syphilis or struma, and to be completely 
beyond the control of remedies, though the continued ex- 
hibition of iodine (a drug unknown when these cases were 
in their early stage) might possibly be of benefit. The 
resemblance these eases bear to one another is very remark- 
able, and there was, a few years back, an attendant at 
Somerset House wdio might have sat for the portrait of Mr. 
Howship's patient. 

In the Museum of St. Bartholomew's Hospital is a 
specimen (I. 62), showing obliteration of the antra, due to 
hypertrophy of the bone, of the same character as in the 
specimen described above, but in an earlier stage, '\\1ien 
the disease affects only one of the maxillae, which is its 
favourite seat, operative interference will be advisable. Mr. 
Stanley (" On Diseases of the Bones," p. 297) gives the case 
of a girl of fifteen years in whom enlargement of the nasal 
process of the sujjerior maxillcB had been observed for eight 
years, and was increasing. There was no external deformity, 
but it was thought advisable to interfere at an early date, 
when it was found that obliteration of the antrum had 
already taken place, as in the preceding case. The entire jaw 
was removed, but the patient unfortunately died of erysipelas. 

In the Museum of King's College is another specimen 
(1201), w^hich shows well the obliteration of the antrum by 
hypertrophy of its walls. The tumour was removed in 1842, 
by Sir William Pergusson, from a girl of twelve, in whom 



FERGUSSON S CASE. 



147 



some enlargement of the face had been noticed from the age 
of fom-, and whose portrait is shown in fig. 55, taken, by 
permission, from that eminent surgeon's " Practical Surgery." 
The patient made a perfect recovery, and tlie particulars of 
the case will be found in The Lancet of February and 
March, 1842. Fig. 56 shows her portrait after recovery 
from the operation. 




In the same museum is a specimen of the disease in the 
ramus of the lower jaw, removed by the same surgeon from 
a girl of thii-teen, by sawing in front of the molar teeth and 
disarticulating. The patient made a good recovery. 

I liave now met with several cases more or less closely 
resembling those described above. The most marked one 
was in a lady, aged thirty-nine, who had a blow on the right 
cheek when fourteen, and noticed an outgrowth when about 
eighteen. When she was brought to me by Mr. Salzmann, 
of Brighton, I found a very marked projection of the right 
cheek, due to an enlargement of the superior maxilla, which 
was smooth and uniform on its surface. Without any external 

l3 



148 HYPEROSTOSIS OF THE JA\VS. 

incision I succeeded in gouging away a ({uantity of dense 
bone without opening any antral cavity, and tlnis reduced 
the face to a symmetrical appearance. The cure has, I 
lielieve, been permanent. 

Lesser degrees of enlargement of both upper and lower jaws 
of the same kind are not very uncommon, and in one or two 
patients I have certainly seen good follow the prolonged 
administration of the syrup of iodide of iron. In the 31st vol. 
of the Patliological Society s Transactions, Mr. R. W. Parker 
gives a drawing of remarkable symmetrical hyperostoses of 
the angles of the lower jaw in a girl of twelve, which he 
considers to be the result of congenital syphilis, and the 
subsequent history confirmed the diagnosis, the gummata 
disappearing under treatment. I have, however, twice been 
consulted for precisely similar hypertrophy of the angles of 
the jaws occurring in perfectly healthy young women, one 
being the daughter of a medical friend, in whom there was no 
suspicion of congenital taint. 

The cases of " Osteitis deformans" described by Sir James 
Paget {Mcdico-Chimrgical Transactions, li.) do not come 
into the same category as the cases given above, for though 
the cranium is often affected, the facial bones have a 
singular immunity from that disease. In several of these 
cases also there was found cancer in some part of the body. 
But that cancer may co-exist with hyperostosis of the jaw 
bones is shown by a case recorded by Dr. Cayley {Patholo- 
gical Society's Trans., xxix.), where cancer of the lung was 
found together with hyperostosis of the lower jaw, which 
presented the following appearances : — " The lower jaw was 
uniformly enlarged and the alveolar border projected beyond 
that of the upper one, with which it could not be brought 
into apposition. All the molar and pre-molar teeth were 
wanting, and the sockets of the molar teeth, except that for 
the first right and the last left one, were filled up with bone, 
the socket of the first right molar was much enlarged and 
would admit the tip of the little finger ; it was continuous 
with the socket for the adjacent bicuspid, which had itself 
ulcerated through tlie anterior surface of the jaw. The 



author's case. 149 

alveolar border of the bone was greatly expanded, especially 
in the molar regions, where it measured in depth two inches 
and a half. The rest of the bone was also greatly increased 
in thickness, the groove and foramen for the inferior dental 
vessels and nerve were remarkably deep and wide. The 
condyle on each side had a short thick neck, and the sigmoid 
notch was wider and less deep than usual. The angle was 
very obtuse, as in edentulous jaws. 

Fig. 57. 




A remarkable case of hyperostosis with liypertroj)hy of 
the tissues of the corresj^onding side of the face has been 
under my notice for fourteen years. The patient, a 
healthy boy, aged twelve, was sent to me in November, 1869, 
by Mr. Giles, of Staunton-on-Wye, under whose care he 
had been from birth. Wlien three months old the patient's 
face was noticed to be enlarged on the left side, and this 
enlargement gradually increased until he presented the ap- 
pearance shown in fig. 57, from a photograph taken in 
1869. The left superior maxilla liad shared in the hyper- 
trophy, and the condition of the palate and teeth is sliown 
in fig. 58^ reduced from a cast, where it will be seen that 



150 



HYPEROSTOSIS OF THE JAWS. 



the temporary incisors and canine teeth are still in situ on 
the diseased side, though they have been replaced "by the 
permanent teeth on the healthy side. I removed the left 
superior maxilla on December 1, 1869, in the hope that the 
removal of the bone and the necessary incisions in the cheek 
would lead to a permanent relief of the deformity. The 
jDatient made a perfectly good recovery, and I subsequently 
endeavoured to open the eye and to destroy a portion of tlie 
tissue of the cheek, but without much permanent success, 
the patient's condition two years after the operation being 
as unsightly as before. I liave recently (1883) received from 
Mr. Giles photographs of this patient, which show that the 
hypertrophy of the soft parts has kept jmce with the patient's 
growth. 



Fio. oS. 



Fig. ,-)9. 




A section of the removed upper juav showed considerable 
condensation of the bone, and the fact that the permanent 
incisors and canine teeth, together with the uncut molars, 
were imbedded in the bone, and holding very much their 
natural relations to the temporary teeth (tig. 59). Mr. 
Charles Tomes, who kindly examined the specimen micro- 
scopically, reported that " the structure is remarkable on 
account of the absence of well- developed regular Haversian 
systems. The bone is everywhere excavated by large 
irregular spaces, around which there is but little aj^pearance 
of lamination, so that it presents some little resemblance to 
so-called ' primary bone' ; the lacuna? are arranged some- 
what irregularly. None of the peculiar branched vascular 



author's case. 151 

canals, figured by Mr. De Morgan in liis account of the 
microscopic characters of Mr. Bickerstetli's case, were ob- 
served in their sections. That the whole of the bone has 
from an early period participated in the morbid action is 
indicated by the fact that, altliough the teeth liave attained 
to something like the stage of development appropriate to 
the patient's age, the alveolar border has not tlie development 
of the jaw in the antero-posterior direction, being insufficient 
to allow of tlie second permanent molar coming down and 
ranging with tlie other teeth. The second molar is a small 
tooth, and tlie wisdom tooth is greatly stunted." 



152 



CHAPTER XI. 



DISEASES OF THE ANTRUM. 



Before entering upon the consideration of the diseases of 
the antrum, it will be convenient to say a few words re- 
specting the anatomical relations of that cavity. Known as 
early as the time of Galen, but connected inseparably with 
the name of Highmore, who described it as " conical and 
somewhat oblono;, " and from whose work fio;s. 60 and 61 are 



Fig. 60. 



Fig. 61. 





taken, the antrum has been more or less correctly described 
by all modern anatomists. Holden compares it aptly 
enough to " a triangular pyramid, with the base towards the 
nose and the apex towards the malar bone ;" and mentions 
the occurrence of " thin plates of bone which are often 
found extending across tlie antrum." The most compre- 
hensive account, however, of the antrum in modern times is 
to be found in a paper by Mr. \Y. A. N. Cattlin, F.R.C.S., 
in vol. ii. of the Transactions of the Odontological Society of 
London, and by the kindness of that gentleman I am enabled 
to reproduce his valuable illustrations. 



ANATOMY OF THE ANTRUM. 



153 



As the result of the examination of a hundred specimens, 
Mr. Cattlin finds that, as a rule, the antrum is larger in the 
male than in the female, and that it diminishes in size with 
extreme age. In the young subject, likewise, the cavity is 
small, and its walls comparatively thick. Fig. 62 shows, in a 

Fig. 62. 




transverse section, both the roof and tioor of an adult antrum 
of the common shape and size, capable of containing two and 
a half drachms of fluid. Fig. 63 is a drawing of a large adult 
antrum capable of containing eight drachms of fluid, whilst 
fig. 64 shows a small adult antrum containing only one 
drachm of fluid. The two antra are often unsynnnetrical in 
size and shape ; thus fig. 65 shows a much larger and deeper 
cavity on one side than on the other. The antrum may 
even extend irregularly into the malar bone, forming a sup- 
plementary cavity there, as seen in fig. 66 (where the view 
is taken from the nasal cavity). The most remarkable vari- 
ation, however, is due to the development of the ridges of 
bone already mentioned, which subdivide the cavity ; these 
are very variable in size and shape. Fig. 67 is an example 
of an antrum divided by a thin plate of bone, and fig. 68 of 
one divided by a thick ridge of bone. Fossa3 of considerable 
depth are often found in the floor of the antrum, par- 
ticularly at the anterior and posterior extremities, of which 



154 



DISEASES OF THE ANTRUM. 



iig. 69 is a good example, showing on one side a perforation 
by an alveolar abscess. A rare form is when fossae or cells 



Fig. 63. 




are developed beneath the orbital plate (fig. 70), or a cnl di- 
me is formed close to the lachrymal groove (fig. 71). 

The position and size of the opening between the antrum 
and tlie middle meatus of the nose are points of some im- 



ANATOMY OF THE ANTRUM. 



155 



portance. The size of the aperture found in a macerated 
superior maxilla gives a very exaggerated idea of the o])en- 



FiG. 64. 




ing in the articulated skuil, when it is encroached upon by 
the palate, inferior turbinate, and ethmoid bones,\vhich narrow 



Fig. 65. 




156 



DISEASES OF THE ANTRUM. 



and subdivide the opening into two. In the recent subject 
these are covered in by the mucous membrane of the nose. 



Fig. G(>. 




so that ordinarily there is only a small oblique aperture left 
in front of the unciform process of the ethmoid, and close 



Fig. 67. 




ANATOMY OF TBE ANTRUM. 



157 



behind the infundiliuhnn. It should be observed, that this 
opening is at the upper part of and not near the lloor of 



Fig. 68. 




tlie antrum, and that it opens into the middle meatus of 
the nose. Occasionally a second small aperture is found 



Fig. 69. 




behind this, and nearer to the floor of the sinus, which has 
been always regarded as a natural formation. M. Giraldes 



158 



DISEASES OF THE ANTRUM. 



liowcver, in liis " Recherches sur les Kystes Muqiieux dii 
Sinus Maxillaire" (Paris, 18G0), maintains tliat the pos- 

FiG. 70. 




terior opening, when it exists, is always tlie result of patho- 
logical change, and that the anterior opening is into the 
infundibulum, and not into the meatus itself. I believe 



Fig. 71. 




SUPPURATION IN THE ANTRUM. 151^>^ 

that slight variations in the position of the opening exist ; 
but it is undoubted that the aperture is very minute, and 
quite inaccessible from the nose. 

Suppuration in the nntrum, or, as it is sometimes termed, 
abscess, is ordinarily the result of inflammation extending 
from the teeth to the lining membrane of the cavity ; and 
the disease might therefore be not incorrectly termed an 
empyema, as proposed by 0. AVeber. The roots of the first 
and second molar teeth often, and the bicuspids and canine 
occasionally, form prominences in the floor of the antrum ; 
and when these teeth become carious, the thin plate of bone 
covering their fangs not unfrequently becomes affected, and 
disease is set up in the cavity. The fangs of the first molar 
tooth are occasionally found in health to be uncovered by 
bone, and to project beneath the lining membrane of the 
antrum ; and under these circumstances, irritation and in- 
llammation would be still more likely to occur. But an 
abscess may be formed in the alveolus, and eventually burst 
into the antrum, though connected originally with teeth not 
usually in relation with the cavity. Of this an example 
will be found in the Appendix, in a case (VII.) given to 
me by Mr. ]\Iargetson, of Dewsbury, where the teeth affected 
were the canine and incisors. This perforation of an alveolar 
abscess is seen also in fig. 69. 

Other causes besides disease of the teeth have been known 
to induce suppuration in the antrum, such as a violent blow 
on the face ; and Dr. Eees has recorded an example, in an 
infant a fortnight old, as the result of pressure during birth 
{Medical Gazette, vol. iv.). It is probable also that the dis- 
ease may result from catarrhal or other inflammation of the 
lining membrane ; and it has been excited by the entrance 
of foreign bodies either from without or from within the 
mouth, after the extraction of a tooth communicating with 
the cavity. In the 3rd volume of the Transactions of the 
Clinical Society, Mr. Moore recorded a case of abscess in the 
superior maxilla, which he believed to be due to the ingress 
of particles of food by the side of a tooth, though the facts 
might possibly bear a different interpretation. 



160 DISEASES OF THE ANTRUM. 

The symptoms of suppuration iu the antrum are at first 
simply those of inflammation of the linmg membrane — dull, 
deep-seated paiii sliooting up tlie face and to the forehead, 
tenderness of the cheek, with some fever and constitutional 
disturbance ; but occasionally tlie pain is most acute, and of 
a sharp, stabbing, neuralgic cliaracter. A slight rigor may 
usher in the formation of matter, which will find its way 
into the nostril when the patient is lying on his sound side, 
either through the normal aperture or through an opening 
caused by absorption, as maintained by M. Giraldes. An 
offensive odour is now sometimes perceptible to the patient, 
though not to those around him — thus differing markedly 
from what occurs iu oztena — and a sudden discharge of 
matter from the nostril when blowing the nose may relieve 
all the symptoms for the moment. The more common course 
of events is, however, that without any acute pain the patient 
notices that he has a purulent discharge from the nose 
when blowing it, and perhaps is aware that, when lying 
down, the discharge finds its way into the throat. This 
latter point is often overlooked, however, though there may 
be a complaint of a very disagreeable taste in the mouth, 
and a tendency to nausea in the morning, with a liawking up 
of pellets of inspissated pus. 

With all this there is no distension of the antrum, and it 
is this fact which frequently misleads the practitioner. It is 
certain, however, that in health there is invariably an 
opening between the antrum and the nostril, and that, even 
when this is closed, the wall is very thin and readily ab- 
sorbed, and it is quite exceptional, therefore, when the 
antrum is so distended with pus as to give rise to any 
prominence of the cheek. Undoubtedly cases of this kind 
have been recorded, but it may be doubted whether some 
of them were not examples of cyst, the contents of which 
had become purulent, for we know that cysts in the wall 
of the antrum readily produce great deformity. The 
natural opening into the nose is not at the level of the 
bottom of the cavity of the antrum, and hence there is 
always a small residuum of discharge, which the patient 



SUPPURATION IN THE ANTRUM. 161 

can only partially get rid of Ijy lioldinL;- the head on one 
side. 

Given, a patient who complains of purulent discharge 
from the nostril, with occasionally a disagreeable smell, and 
the case is too apt to he put down as one of ozsena, and 
treated by nasal douches, snuffs, &c. But, as already men- 
tioned, the offensive smell is perceived only by the patient, 
and not by his friends, the reverse being the case in oztena ; 
and, again, the discharge is only occasional, is determined 
by the position of the head, and is simply purulent, whereas 
in ozfena the discharge is constant, and mixed with offensive 
crusts from the nasal cavities. Again, the dull ache, varied 
occasionally by acute pain, is apt to be referred to the teeth 
alone, and the most careful examination may fail to detect 
any special tenderness in any one tooth. Hence, after ex- 
hausting the usual routine remedies for neuralgia, I have 
known wholesale extraction of useful teeth undertaken with 
no benefit, unless it should fortunately happen tliat the 
tooth which has perforated the antrum should be extracted 
early, when the discharge of pus at once clears up the nature 
of the case. 

The more ordinary consequence, however, of an unrecog- 
nised empyema of the antrum is the damage done to the 
digestive organs, by the constant swallowing of purulent 
fluid during sleep. Under these circumstances, the patient 
is always ailing, is unable to take food in the morning, and 
may be reduced to a state of great prostration, even danger- 
ous to life. The usual remedies for indigestion are likely to 
be of little service so long as the purulent drain continues. 

In exceptional cases the pus, not finding an exit, distends 
the antrum, causing partial absorption of the walls, and thus 
both bulging out the cheek and thrusting up the floor of 
the orbit. Tig. 72 shows the prominence of the cheek thus 
produced in a patient under the care of Sir William 
Fergusson. Under these circumstances the affection is 
readily recognised by the peculiar crackling which is per- 
ceived when the thinned bone is pressed upon, and the 
matter, if not evacuated, will shortly find a way out for 

M 



162 



DISEASES OF THE ANTRUM. 



itself, either Ijy the side of the teeth, thruuoh the front wall 
of the antrum, or through the floor of the orbit ; in either 
of which cases considerable necrosis and ultimate scar are 
likely to be the consequences. 

The possibility of both antra being affected either simul- 
taneously or consecutively, must not be overlooked. I have 
a patient now under my care whose right antrum I emptied 

Fig. 72. 




some years back, and who has now symptoms which point 
to the presence of matter in the opposite antrum, and Mr. 
C. Tomes has met with the same occurrence. 

The elevation of the floor of the orbit already described 
may simply displace the eyeball and render it temporarily 
blind, as in a case recorded by Mr. J. Smith, of Leeds, 
{Lancet, Feb. 14, 1857), or it may lead to permanent amau- 
rosis — a point to which Mr. Salter called especial attention 
in the Medico-Chirurgical Transactions for 1862. Mr. 
Salter's patient, a young woman, twenty- four years of age, 
was attacked with violent toothache in the first right upper 



AMAUROSIS FROM ANTRAL DISEASE. !(;;> 

molar, which was followed by enormous swelling of the side 
of the face and intense jmin. The eyeball then became 
protruded, and she soon after perceived that the eye was 
blind. Shortly after the establishment of these symptoms, 
" abscess" of the antrum pointed at the inner and then at 
the outer canthus, and a large discharge of pus at both 
orifices followed ; these orifices soon closed, but the general 
symptoms of the part continued unchanged — the swelling of 
the face, protrusion of the globe, and blindness. This state 
of things lasted for about three weeks, when the patient was 
sent to Guy's Hospital, and admitted. At this time the 
patient exhibited hideous disfigurement from swelling of the 
face, oedema of the lids, and lividity of the surrounding 
integument. Upon examining the moutli, it was found that 
the carious remains of the first right upper molar appeared 
to be associated with, and to have caused the disease. 
Too-ether with the other contiouous carious teeth, this was 
removed, and led by an absorbed opening into the floor of 
the antrum. The haemorrhage which followed the operation 
was discharged partly through the nose, and partly through 
the orifices in the cheek, as well as from the tooth-socket, 
showing a common association of these openings with the 
antrum. The condition of the eye constituted the most im- 
portant symptom, and the most distressing. The sight M^as 
utterly gone ; the globe prominent and everted. There was 
general deep-seated inflammation of the fibrous textures of 
the eye. The pupil was large and rigidly fixed; it did not 
move co-ordinately with the other under any circumstances. 
Some abatement of the symptoms followed the extraction of 
the tooth ; but it was soon found that there was a consider- 
able sequestrum of dead bone, which was removed. The 
necrosis involved the front part of the floor of the orbit, 
the cheek surface of the superior maxilla, with the infra- 
orbital foramen, and a large plate of bone from the inner 
(nasal) wall of the antrum. The removal of the dead bone was 
followed by the immediate and complete cessation of all in- 
flammatory symptoms ; but the eye remained sightless, and 
the pupil rigidly fixed. About five weeks after the removal 

M 2 



164 DISEASES OF THE ANTRUM. 

of the dead bone, it w<as noticed that tlie pupil of the 
affected eye moved with that of the other, under the 
influence of lio-ht, though vision in it had not returned. Mr. 
Charles Gaine, of Bath, has recorded {British Medical Journal, 
Dec. 30, 1865) a very similar instance in a young woman 
of twenty-two. In Mr. Salter's paper will be found the 
case of a gentleman, aged thirty-five, under the care of Mr. 
Pollock, who had amaurosis following inflammation without 
abscess, and one by Dr. Briick, where amaurosis followed 
abscess, in the person of a man of forty-five. Sir Thomas 
Watson, in his " Lectures on Physic," alludes also to two 
cases of temporary amaurosis, the result of diseased teeth in 
the upper jaw. 

But even more serious results have followed neglected 
suppuration in the antrum, for Dr. Mair, of Madras, has 
recorded, in the Udinburr/h Medical Journal for 1866, the 
case of a gentleman in whom suppuration in the antrum was 
followed by death in sixteen days, from suppuration within 
the cranium accompanied by epileptic convulsions. The 
full details of the case, with the most interesting post-mortem 
appearances, will be found in the Appendix (Case VIII.). 

The treatment of suppuration of the antrum consists, in 
the first place, in the extraction of all decayed teeth or 
stumps in the affected jaw, and with this object in view 
those teeth which are apparently sound should be tested by 
a sharp knock with some metal instrument, when, if tender, 
they should be extracted. If the cause of the mischief is 
removed in time, the inflammation will subside under fomen- 
tation and the application of a leech to the gum ; but if 
matter has formed it must be evacuated without delay. If 
the extraction of a tooth is followed by the flow of pus, the 
enlargement of the aperture in the socket by the introduc- 
tion of a trocar is at once the readiest and simplest mode of 
evacuating the matter ; but if all the teeth are apparently 
sound, it will be advisable to perforate the alveolus above 
the gum with a trocar, gimlet, or strong pair of scissors, and 
similar treatment would be required in the rare case of suppu- 
ration occurring after loss of the teeth in old people. If it is 



TREATMENT OF SUPPURATION. 1G5 

determined to sacrifice a tooth the first molar is to be pre- 
ferred for extraction, both on account of the depth of its 
socket and also l)ecaiise, as mentioned by Salter, it is more 
liable to decay than the other teeth. In puncturing through 
the socket of a tooth with a trocar it is well to gauge the 
depth to which the instrument may safely go with the 
fingers of the hand which grasps it, lest injury should be 
unwittingly inflicted on the orbital plate by the trocar 
entering unexpectedly, or a trocar with a stop may be em- 
ployed if preferred. 

After considerable experience of both methods I prefer 
the puncture above the alveolus, except when a tooth 
obviously requires extraction, because I find that the aper- 
ture is less liable to close up than when made through the 
alveolus, and because food is less likely to find its way into 
the antrum. It is necessary, however, not to direct the 
trocar cpiite horizontally but a little upwards, lest in a case 
of highly arched palate the floor of the antrum should be 
injured, as I have knowai on one occasion, but then fortu- 
nately with no permanent damage, except the exfoliation 
of a minute portion of the palate. 

Wliatever method may be adopted for emptying the an- 
trum, it is important that the cavity should be thoroughly 
cleansed by the forcible injection of warm water until it 
runs freely from the nostril. For this purpose an ordinary 
glass syringe is quite insufficient, but I have satisfactorily 
employed an ordinary Eustachian catheter for the purpose, 
to which an india-rubber injecting-bottle is adapted. After 
a time, and with a little instruction, patients can learn to 
dispense with the syringe by forcing a mouthful of water 
through the antrum by the action of the buccinator muscles. 
After thoroughly cleansing, some detergent and slightly 
astringent lotion should be injected, to restore the healthy 
condition of the mucous membrane, and for this purpose 
weak solutions of permanganate of potash or sulphate of zinc 
answer admirably ; but these cases are exceedingly tedious, 
as a rule, and take many months for their cure. If the 
perforation has been made through the socket of a tooth, 



166 DISEASES OF THE ANTRUM. 

cure must be taken that particles of food do not gain admis- 
sion to the antrum, and this may be accomplished by plug- 
ging the hole with cotton wool, or, as suggested by Salter, 
by fitting a metal plate to the mouth with a small tube to 
fill the apertuie, which can be corked at pleasure, and will 
serve as a pipe for injection. 

Ordinarily the pus is readily evacuated through the nostril, 
but I have seen large masses of offensive inspissated pns block 
up the opening into the nose and require very forcible and 
repeated syringing for their removal, and the same thing 
applies to clots of blood, which occasionally give trouble. A 
still more serious event is when a mass of inspissated pus 
gives rise to symptoms closely resembling those of a tumour 
of the upper jaw and without producing that absorption 
wliich gives rise to the crackling characteristic of the presence 
of fluid. The following case of this kind occurred in my 
own practice, and Mr. Mason published a very similar one. 
A woman, aged forty-three, w^as admitted under my care, 
complaining of pain and swelling of the left side of the face. 
There was an ill- defined swelling over the region of the left 
upper jaw, and the angle of the mouth on that side was 
drawn downwards. The swelling was both hard and tender ; 
the skin over it appeared unaffected. In the mouth there 
was a tense, ela.stic, and tender swelling over the left half of 
the hard palate, displacing the alveolar process doAvnwards. 
Slight discharge oozed from a small opening in the mucous 
membrane opposite the last upper molar tooth, the swelling 
being softer about this spot tlian elsewhere. The left nostril 
was blocked, its external wall l)eing pushed inwards, and the 
patient complained of some discharge fi'om it. The neigh- 
bouring lymphatic glands were not enlarged, and with the 
exception of occasional pain in the tumour the patient 
suffered no inconvenience, her general health being excellent. 
She had noticed the swelling for about two years, and 
its commencement was attributed to exposure to cold. At 
times the swelling increased, and became more troublesome, 
especially after prolonged overwork. No history of syphilis 
could be obtained, and her famil}' history was good. 



CHRONIC ABSCESS OF ANTRUM. 167 

Believing that I had to deal with a solid tumour of the 
jaw, I made an incision through the upper lip in the median 
line, prolonging it into the nostril of the affected side. The 
alveolus and hard palate having been divided with saw and 
bone forceps, a way was made into the latter, and a pul- 
taceous offensive mass, about the size of a hen's egg, was 
turned out with the finger. On microscopical examination 
this was found to consist of fatty debris, granular pus cells, 
and acicular crystals. As the larger portion of the left half 
of the hard palate was partially loosened and absorbed it 
was removed with the forceps. The cavity of the wound 
was stuffed with a strip of lint, and the patient made an 
uninterruptedly good recovery. 

The possible subdivision of the floor of the antrum by bony 
septa, already described, must be borne in mind in operating 
upon this cavity, and especially if there is reason to suspect 
the presence of any foreign body which may be keeping up 
irritation. In his paper already referred to, Mr. Cattlin 
narrates the case of the fang of a tooth lodging in one of 
these subdivisions, from which it was extracted with difficulty. 

Suppuration in the antrum may assume a more chronic 
form than that above described, and from the slow expansion 
of the jaw which results may be mistaken for a solid growth. 
Weber describes a form of chronic subperiosteal abscess pro- 
ceeding from a tooth, which is surrounded by an osseous 
plate or shell formed from the periosteum, while it is sepa- 
rated from the antrum by the maxillary wall itself ; and 
believes that the occurrence of suppuration commencing in 
the bone, either from this cause or from the suppuration of 
a dentigerous cyst, is much more common than in the antrum 
itself, but in this I do not agree, though recognizing the 
occasional occurrence of the form of abscess described. The 
diagnosis of these several forms of abscess is by no means 
easy, and errors have been made by excellent surgeons in 
mistaking them for solid growths : thus, Liston mentions 
("Practical Surgery," p. 303) having seen a sm"geon 
have his hands covered with purulent matter in attempting 
to remove a supposed tumour of the jaw. This is more 



108 DISEASES OF THE ANTRUM. 

especially likely to happen when, as is sometimes the case, 
considerable hypertrophy of the osseous wall has taken 
place in consequence of the irritation the bone has been 
subjected to. Stanley (p. 285) mentions a case of the kind 
which occurred in the practice of Sir W. Lawrence : — " A 
woman, aged twenty-four, was admitted M'ith a large, hard, 
round swelling of the cheek in the situation of the antrum ; 
it was free from pain, and the soft parts covering it were 
healthy ; such was the solidity and hardness of tlie swelling 
that it was supj)osed that it might be an osseous growth from 
the antrum, and the history appeared to confirm this view of 
its nature, as the woman stated that about five months 
previously she had received a blow on the cheek, and that 
soon afterwards the swelling commenced, and had slowly 
increased to its present magnitude, which was about that of 
a middle-sized orange. A scalpel was thrust into the tumour 
immediately above the sockets of the molar teeth, and healthy 
pus flowed from the opening; the discharge continued in 
gradually decreasing quantity, and the swelling subsided as 
the walls of the antrum receded to their natural limits." 

This thickening of the bone may remain permanently, 
long after the cure of the abscess, and may necessitate ope- 
rative interference : thus, in 1850, Sir William Fergusson 
met with a case of osseous tumour of the size of a pigeon's 
egg, projecting from the superior maxilla of a man aged 
fifty, who had been the subject of abscess, and whose antrum 
was still distended, though containing no fluid. Here it be- 
came necessary to remove the tumour with the anterior wall 
of the antrum, by which the deformity was quite got rid of. 
The case will be found in the Lancet, June 29, 1850. A 
case, under the care of Mr. Henry Smith, in which an ab- 
scess consequent on necrosis of a portion of the jaw closely 
simulated a tumour of the antrum, will also be found in the 
British Medical Journcd, March 2, 1867. 

Hydrops Antri, or " dropsy of the antrum," is an old 
name (whicli should, I think, be abandoned) for a disease 
wliich has long been recognised, though, within the last few 
years, opinions have changed as to the exact piathology of 



DISTENSION OF THE ANTRUM. 109 

the affection. The history of these cases is one of gradual, 
painless dilation of the upper jaw^ until its outer wall be- 
comes so thin as to crackle like parchment upon pressure 
being made, or at certain points being so absorbed that 
fluctuation is readily perceptible. Occasionally the other 
walls of the jaw yield, though more slowly, to tlie persistent 
pressure, the palate becoming flattened, and the nostril 
blocked by the bulging of the internal wall. On the ex- 
traction of a molar tooth and perforation through its socket, 
as described under the previous section, or more frecpently 
by an incision through the osteo-membranous wall of the 
cyst, a quantity of clear, or yellowish serous fluid is evacu- 
ated, which frequently contains flakes of cholesterine floating 
in it. After the evacuation of the fluid the swelling ordi- 
narily subsides, the maxilla resuming its normal relations, 
and the opening closing. 

The old explanation of these phenomena was, that the 
aperture between the antrum and the nostril having become 
accidentally obstructed, the mucous secretion, which was pre- 
sumed to be constantly taking place within the cavity, was 
thought to be imjDrisoned, and, by its gradual accumulation, 
to produce the symptoms which have been described. Fol- 
lowing up this idea, we find surgeons, and among others 
Jourdain, of Paris (1765), who very accurately described the 
affection, recommending the restoration of the nasal orifice 
by probing — a useless operation, still described in many 
foreign manuals of operative surgery (see Guerin's " Elemens 
de Chirurgie Operatoire," 1855). Bordenave, in his " Obser- 
vations on Diseases of the Maxillary Sinus" (Sydenham 
Society's translation, 1848), gives full details of this method 
of probing and injecting, but, after showing that there is 
great difficulty and uncertainty in finding the natural orifice, 
remarks that "there are very few cases in which the employ- 
ment of injections through the natural openings, in the 
manner above described, would effect a complete cure." 
It is certain, however, that some of these cases, and very 
probably all of them, originate in the growth of a cyst, or 
cysts, within the antrum, or more commonly in the wall of 



170 



DISEASES OF THE ANTRUM. 



tlie antrum, which eillier grow to sucli a size as to be mis- 
taken for the cavity of the antrum when opened, or break 
into the antrum by absorption of the cyst-wall, so that on 
subsequent examination no evidence of cyst formation can 
be discovered. This explanation is, as pointed out by 
Coleman, supported by the fact that in these cases of so- 
called hydrops antri, the contained fluid in no respect 
resembles ordinary mucus, but is invariably a clear, more or 
less yellow fluid, frequently containing cholesterine in con- 
siderable quantity. In these respects it closely resembles 
that found in well-marked cases of cystic growth, which 
have been examined in various stages of development. 




A remarkable case of distension of the antrum is narrated 
by Sir William Fergusson, and the preparation is preserved 
in the King's College Museum. It was taken many years 
ago from a subject in the dissecting room, and from the 
person of an old woman. The tumour, which was of very 
large size, had burst shortly before death, leaving the 
remarkable deformity shown in fig. 73 (taken by permission 
from Sir W. Fergusscn's work on Surgery), which is due 
to the complete absorption of the front wall of the antrum 



CYSTS IN THE ANTRUM. 171 

and its collapse, by which a prominent horizontal ridge of 
bone, fcjrmed by the upper wall of the antrum, has been left 
immediately below the orbit. The preparation shows great 
distension of the antrum, the diameter of which varies in 
different parts from two to two and a half inches, and the 
bony wall is so thinned out as to resemble parchment. The 
gums are edentulous. There is no communication between 
the nose or moutli and the cavity, which is lined with a mem- 
brane covered witli laminated deposit. (For these particulars 
I am indebted to Dr. Trimen, the late Curator.) Whether 
tliis was originally a case of cystic growth, or a chronic 
abscess, it is impossible now to decide, but it is, so far as I 
am aware, a unique post-mortem specimen of this distension. 
Numerous instances of so-called distension of the antrum 
by cleai- fluid in living patients, have been recorded from 
time to time, and occasionally mistakes have been made by 
the surgeon in regarding the tumour as of a solid nature. 
A very remarkable case, in which a distended antrum closely 
simulated a solid growth, occurred in the practice of Sir 
William Fergusson, and the details of the case will be 
found in the Lancet, June 29, 1850. Here the surgeon 
made an exploratory puncture before commencing the more 
serious operation ; but a case has occurred within my own 
knowledge, in which a very able surgeon removed the upper 
jaw before discovering the error of his diagnosis. 

M. Giraldes would appear to have been the first author 
upon the subject of cysts of the antrum, and his thesis 
gained the Montyon prize in 1853 : but Mr. W. Adams may 
fairly claim priority of investigation, as shown by specimens 
preserved in St. Thomas's Museum — as indeed is acknow- 
ledged by M, Giraldes. Luschka subsequently investigated 
the subject, and in sixty post-mortem examinations found 
cystic growths in the antrum five times, some of them being 
two centimetres in length. A careful examination of the 
antra of thirty subjects, made for me by Mr. IMarcus Beck, 
then Demonstrator of Anatomy of University College, during 
the winter of 1867-68, failed to discover an instance of the 
kind. 



172 



DISEASES OF THE ANTRUM. 



]\Ir. Adams' sixciinens, from one of wliicli the drawing 
(fig. 74) was made, show each a cyst of oval outline, attached 
to the inner wall of the antrum, and measuring rather more 
than an inch, and three-quarters of an inch respectively, in 
their long diameters. These, of course, are too small to 
have produced any symptoms during life. The specimens 
given by M. Giraldcs in his " Eecherches sur les Kystes 
Muqueux du Sinus Maxillaire," from one of which the 
illustration (fig. 75) is taken, show very varying degrees of 
cystic growth in the mucous membrane of the antrum. In 

Fig. 74. 




one instance there is a single cyst at the fioor of the antrum, 
into which an opening has been made, whilst in the others 
the cysts are very numei'ous and of very variable sizes, 
depending, apparently, upon a cystic degeneration of the 
entire mucous membrane. M. Giraldcs explains the forma- 
tion of these cysts as being due to the dilatation of the 
glandular follicles of the mucous membrane, and urges that 
the ordinary operation of tapping the antrum would be 
useless in such cases, but that it would be necessary to open 
up the antrum, so as to get at the seat of the disease. 
Fortunately these numerous cysts appear to be of slower 



CYSTS IN THE ANTRUM. 



173 



gi'owth than the single cysts, for it would be impossible to 
extirpate such numbers as are here seen (tig. 75), without 
removing the entire jaw. 

The contents of these cysts appear to be at first clear 
fluid, but of a viscid nature ; when more fully developed, 
the fluid becomes flaky, from the presence of cholesterine, 
and occasionally assumes a greenish tint ; it may also become 
purulent,and Maisonneuve has recorded {Gazette des Hopitaux, 
Jan. 6, 1855) a case where pressure on the cheek pro- 
duced a flow of butter-like fluid from the nose in a young 
woman who, for a year, had suffered from a tumour of the 
right upper jaw, which had been pronounced malignant, the 

Fig. 75. 




face being enlarged and the nostril obstructed. Here 
puncture from the nostril, combined with pressure and in- 
jections, effected a cure, and the case must be considered as 
one of cyst of the antrum, but whether a mucous cyst, the 
contents of which had undergone solidification, or a separate 
formation, must remain doubtful. 

Treatment. — The treatment of cystic disease of the jaw 
is generally sufficiently simple. The bony wall being 
most commonly, to some extent, absorbed, it is only necessary 
to incise the distended membrane and evacuate the fluid. The 
finger then passes readily into the cyst and can examine its 
interior, searching for any growth or tooth whicli may be 



174 DISEASES OF THE ANTRUM. 

lodged within. "Witli curved scissors the opening can then 
be enlarged by cutting away tlie membranous wall, suffi- 
ciently to allow a free passage for any discharge. The use 
of a simple stimulating lotion with a syringe is then all 
that is required to effect a cure, which, though slow, is 
permanent. I have treated a considerable number of cases 
of cyst of the jaw in this manner, and with uniformly good 
results. 

Broca (" Tumeurs," vol. ii. p. 37) recommends to remove 
tlie membrane covering the inner wall of the cyst, and gives 
a case in which Nelaton discovered a plate of bony tissue 
derived from a malformed tooth on the inner aspect of a 
cyst, but this is in most cases a c[uite unnecessary complica- 
tion of what is usually a very sun pie matter. 

Polypus of the Antrum. — This is not a common aftection, 
though by no means so very rare as stated by Paget. 
Luschka has investigated the subject (Virchow's " Arcliiv," 
Bd. viii. p. 419), and found polypi five times in sixty sub- 
jects, some being two centimetres in length. He gives a 
drawing, sliowing a large number of these polypoid growths 
in an antrum, which he considers to be hypertrophies of the 
submucous connective tissue, covered with mucous membrane. 
Billroth also describes a good example of large polypus of 
the antrum with a long pedicle, and regards it as a very 
rare affection, and there is a good specimen in University 
College Museum. 

These polypi are closely allied apparently to the small 
cystic growths in the mucous membrane of the antrum, 
described by Giraldes. Both affections consist essentially in 
hypertrophy of some elements of the mucous and submucous 
tissues. When the connective or areolar tissue predominates, 
the fleshy polypus is produced ; when the glandular element 
is especially affected we have the cystic form produced. 
Intermediately, when the fibrous element is very loose and 
we have some glandular hypertrophy, the semi-gelatinous 
polypus is produced, which closely resembles the nasal 
polypus. 

Polypi of the antrum are well supplied with blood-vessels, 



POLYPUS OF THE ANTRUM. 175 

and bleed freely when interfered with. In some instances 
they appear to have a malignant character, or at least are 
the forerunners of malignant disease occurring in the antrum 
and jaw. Vidal de Cassis, who (" Traite de Pathologie 
Excerne," tom. iii. p. 492) totally denies the existence of 
any true polypoid growths in the antrum, says that what 
have been mistaken for them most frequently are colloid 
tumours of the periosteum, but believes that many of the 
examples are cases of cystic growth. Syme also, following the 
example of John Bell, maintains that polypi in the antrum 
always intrude from the nose, and are never developed in 
the antrum itself. {Lancet, May 10, 1855.) 
- Sir James Paget has put on record {Clinical Soc. Trans. 
xii.) a case of polypus of the antrum in which a constant 
flow of clear watery fluid from the nose was the only 
symptom. At the post-mortem examination " the floor of 
the antrum was covered with two broad-based convex poly- 
poid growths, deep clear yellow with the fluid infiltrated in 
their tender tissue, and covered with exceedingly thin smooth 
membrane traversed by branching blood-vessels. They 
were of rounded shape, about two- thirds of an inch in 
diameter and half an inch in depth ; they looked like very 
thin-walled cysts, but were formed of very fine membranous 
or filamentous tissue, infiltrated with serum." 

Ordinarily the symptoms of polypi, no less than of cysts 
of the antrum, only become developed when the growth is 
of sufficient size to encroach upon the neighbouring cavities, 
or produce distension and absorption of the front of the 
antrum. The most common situation for the polypus to 
show itself is, as might be expected, the nose, since the 
tumour readily induces absorption of the thin nasal wall of 
the antrum. Here it closely resembles tlie ordinary nasal 
polypus, and Sir William Fergusson mentions (" Practical 
Surgery," p. 561) two cases of the kind in which this had 
occurred, one being in his own practice. In that instance 
he soon found that he had attacked a tumour of the antrum, 
which, in consequence of its deep and firm attachment, and 
the great haemorrhage attending it, he did not entirely 



176 DISEASES OF THE ANTRUM. 

remove. The disease returned, and he again operated, on 
this occasion using great force, and wrenclied out the whole 
mass, not without some fear of the consequences. The 
case, however, did well, and after ten years the disease had 
not returned. 

In the Medical Times and Gazette, March 18, I860, is 
a report of another case in which the same surgeon re- 
moved a vascular fibrous polypus of the antrum wliich had 
projected into the nostril, by laying open the front wall of 
the cavity, and with strong forceps tearing out the tumour 
bit by bit. 

I had, during 1866, the opportunity of watching the case 
of a patient who had had a polypus partially removed by 
the nose on several occasions, and from whom Mr. Holthouse 
removed an entire growth a year and a half before that 
date. He re-appeared with a swelling of tlie jaw, evidently 
due to distension of the antrum by some soft growth, and 
he had also a soft tumour on the forehead. These were 
doubtless cancerous, for his strength failed, and he sank 
after some months, but unfortunately his relations would 
not permit a post-mortem examination to be made. 

Hypertrophy of the glandular tissue of the mucous mem- 
brane appears capable of producing tumours of a friable 
description, which may fill up the antra on both sides, as in 
a case recorded by M. Demarquay {Gazette Mediccde dc 
Paris, November 4, 1857). Here the patient had a large 
tumour on each side of the nose, the passages of which were 
completely obstructed, and his right eye w^as protruded from 
the orbit. M. Demarquay removed the front walls of the 
antra, and extirpated two masses of very friable tissue of a 
greyish-white colour, in which the vascular tissue was not 
abundant. M. Eobin, who examined the growths, pro- 
nounced them to be the result of an hypertrophy of the 
glandular element of the mucous membrane of the antrum. 

A curious, and I believe, unique case of falling in of the 
antrum, recorded by Mr. White Cooper, may be conveniently 
mentioned here, since the depression of the wall of the 
cavity depended, no doubt, upon some alteration going on 



FALLING IN OF THE ANTRUM. 177 

in its interior — possiljly tlie aljsorption of some fluid which 
had previously induced thinning of the bones. The patient 
was brought before the Medical Society of London in 1851, 
and Mr. Cooper has kindly given me the following details of 
her case : — 

" I first saw Margaret Eyan (aged twenty-seven) May 
22, 1849. 

" Complained of the tears running over the left cheek, 
first perceived about a week previously. 

" Seven years ago first observed a black mark round the 
lower part of the left eyelid ; without pain, weakness of eye, 
or toothache. Gradually and almost imperceptibly flattening 
of the cheek came on. 

" The appearance presented was that of a deep depression 
between the malar bone and nose, precisely as if a portion of 
the superior maxillary bone had l)een cut away. 

" It was bounded superiorly by the inferior margin of the 
orbit, which partook of the depression ; inferiorly by the base 
of the alveolar process ; and externally by the malar bone. 
As comjDared with the other cheek, the dimensions were as 
follows : — From bridge of nose over deepest point of de- 
pression, one inch four-tenths, or nearly an inch and a half ; 
right side to corresponding point just one inch. 

" There was a peculiar dusky hue about the depression, 
especially towards the upper part. The cuspid and bicuspid 
teeth were removed with considerable difficulty, the roots 
showing thickening of periosteum. 

" No change was visible at the expiration of twelve 
months." 



N 



178 



CHAPTER XII. 



CYSTS OF TEETH DEXTIGEROUS CYSTS. 



Cysts in counectiou with the teeth may be classed under Uvo 
heads : — 1st, cysts connected with the roots of fully de- 
veloped teeth, and 2ndly, cysts connected with imperfectly 
developed teeth — to which the term " Dentigerous cysts" 
has been applied in modern times. Both kinds may occur 
in either jaw, and, in the case of the upper jaw, may be 
confounded with collections of fluid in the antrum, or may 
secondarily involve that cavity. 

Cysts, of small size, in connection with the fangs of per- 
manent teeth, are frequently found on their extraction, but 
give rise to no symptoms demanding surgical interference, 
though sometimes they cause pain from pressure on the 
dental nerves. Occasionally, however, they grow to a large 



Fig. 76. 



Fig. 77. 



Fig. 78. 




size, in which case they produce absorption of the containing 
alveolus, and give rise to a prominent swelling. They lie 
beneath the periosteum of the fang, and hence have been 
named by Magitot (Arch. Gen. dc M^dccine, 1872-73) peri- 
osteal cysts. The contained fluid is rich in cholesteriue. 
Three specimens of cyst connected with the fangs of teeth, 



CYSTS OF TEETH. 179 

for which I was indebted to Mr. Holborow King, accom- 
panied tliis essay, and are now in the Museum of the College 
of Surgeons (2161). Two of them (figs. 11 , 78) are quite 
small (one being remarkable for the length of its pedicle), 
the third (fig. 76) is of the size of a hazel-nut, and was torn 
in extraction. The contents of the cyst were found on 
microscopic examination to consist of degenerating pus ; 
their walls were formed of fibrous and granulation tissues, 
and they had no epithelial lining. This would confirm the 
view of Mr. Tomes, that the morbid process is probably 
identical with that resulting in the formation of alveolar 
abscess, but being less acute, a serous cyst is formed instead 
of a suppurating sac. In the Museum of the College of 
Surgeons is another specimen of a vascular thick-walled 
cyst, attached to one side of the fang of an incisor tooth 
(.2161a). 

Large cysts, which produce more or less absorption of the 
outer wall of the maxilla, are, in my experience, very common 
consequences of the retention of diseased teeth, but seem to 
give surprisingly little inconvenience to the patients, even 
when of large size and producing considerable deformity of 
the face. They are commonly confounded with cystic dis- 
tension of the antrum. 

Dupuytren remarks that " morbid changes in the roots of 
the teeth give rise to the formation of serous cysts, which 
are most frequently met with in the alveoli of the upper 
canines, and in some instances acquire a very large size, 
even equal to that of the antrum. In such cases the root 
of the tooth is found diseased and inclosed within the cyst, 
which adheres to the alveolar cavity, and (when small 
enough) usually accompanies the tooth in its extraction ; 
but if left behind, a suppurative process is established, wliich 
continues for a long time. The fluid yielded by these cysts 
is sometimes very thick, and in other instances of a serous 
character, and their inner surface is as smooth as that of the 
serous membranes" (" On Diseases of Bone," Sydenliam 
Society's Translation, p. 440). 

Of this kind probably also was the case mentioned by 

N 2 



180 CYSTS OF TEETH. 

Sir J. Paget (" Surgical Pathology/' p. 402), of a woman, aged 
thirty-eight, who had a tumour simulating a collection of 
fluid in the antrum, but which projected beneath the mucous 
membrane of the upper jaw above the teeth, and had 
existed six years. An incision evacuated an ounce of turbid 
brownish fluid, sparkling witli crystals of cholesterine, and 
it then appeared that there was no connection Avith the 
antrum, but that it rested in a deep excavation in the alveolar 
border of the jaw. So also the case mentioned by the same 
author in connection with the incisor teeth. 

Delpech relates a case in which a membranous cyst con- 
tained three ounces of fluid, but its interior bore no re- 
semblance to the interior of the antrum ; and Stanley 
(p. 300) narrates a case of Sir W. Lawrence's of large cyst 
projecting in the situation of the antrum, and containing a 
glairy fluid with shining particles in it, and regards both 
cases as instances of cysts connected with the teeth, although 
it appears more probable that they were examples of cyst in 
the antrum, such as have been already described. 

A case, whicli I have little doubt originated in a cyst in 
connection with the incisor teeth, but in which the antrum 
had become secondarily involved, has lately been under my 
own care. The patient, a woman aged forty, had a fluc- 
tuating swelling, noticed for two years, immediately above 
the incisor teeth, wliich were decayed even with the gum. 
On incising it, a quantity of yellowish glairy fluid exuded, 
and a probe, when introduced, evidently passed into the 
antrum. From the position of tlie cyst, and its close proxi- 
mity to the incisor teeth, I have no doubt it originated from 
them, and found its way into the antrum by absorption of 
the bony wall. The patient would not consent to any 
operation for the cure of the disease, whicli gave her little 
inconvenience. 

Fischer, of Ulm (Gurlt's " Jahresbericht," 1859, p. 154), 
has narrated three cases of cyst connected witli the fangs of 
teeth, in one of which he had the opportunity of making a 
post-mortem examination. After the removal of the facial 
wall of the antrum, there appeared a cyst connected with 



CYSTS OF TEETH. ' 181 

the apex of the posterior molar tooth, which filled the whole 
antrum without, however, adhering to the mucous mem- 
brane. This consisted of a perfectly closed serous bag of 
^'" thickness, with a smooth inner surface, and containing 
a yellowish serous fluid, which grew from the periosteum of 
the apex of the root of the tooth. 

The clinical history of cysts connected with tlie teeth is 
that of painless expansion of the alveolus of either jaw, but 
more frequently of the upper, with crackling of the bone on 
pressure and ultimate absorption of the bony wall. The 
cyst then presents a bluish appearance through the distended 
mucous membrane, and if large, gives distinct evidence of 
fluctuation. 

Treatment. — An incision into the cyst evacuates a dark- 
coloured clear fluid, unless inflammation should have been 
excited, when the contents become purulent. It is advisable 
to cut away the thin outer wall of the cyst freely with 
scissors, or, if necessary, with bone-forceps, so that the cavity 
may granulate up. If an incision only is made, the edges 
are apt to fall together and re-unite with a reproduction of 
the fluid, unless an india-rubber drainage-tabe is inserted, 
which can 1)e attached by a thread to a neighbouring tooth. 

Single Cysts in the lower jaAV' as in the upper, may origi- 
nate in connection with the fully-developed teeth, and as in 
the case of dentigerous cysts, may give rise to the suspicion 
of a more severe affection. In April, 1867, a case of the 
kind occurred in King's College Hospital in the person of a 
boy aged ten, who appeared to have a solid tumour of the 
body of the lower jaw on the right side, rather larger than 
a pigeon's egg. Sir William Fergusson discovered a slight 
yielding of the osseous wall, which crackled upon being 
j)ressed, and upon extracting a neighbouring tooth a quantity 
of glairy fluid escaped. The treatment was completed by 
cutting away a part of the expanded outer plate of the 
bone, and making the wound heal from the bottom. 

According to Broca (" Traite des Tumeurs," vol. ii. p. 35) the 
great majority of cysts of the jaws have their origin in tooth 
follicles. These are shut sacs, but they do not enclose a true 



182 CYSTS IN THE LOWER JAW. 

cavity, for the space between the wall aud the outer surface 
of the dental papilla is occupied by the enamel-organ, an 
organized body, but very soft and gelatinous, apt to disappear 
under morbid influences, and thus leaving in the follicle a 
cavity ready to be transformed into a cyst. Dental cysts 
may originate in the follicles of the first or second dentition, 
or in the follicles of supernumerary teeth. Their contents 
are ordinarily clear fluid, sometimes bloody, occasionally 
filamentous or gelatinous, and still more rarely they contain 
a sebaceous matter like mastic, composed almost entirely of 
epithelium. 

But periosteal cysts occur in the lower jaw without any 
apparent immediate connection with the teeth, though very 
possibly some irritation connected with these organs may have 
been the original cause of the mischief, The patient finds 
that he has a slowly-growing tumour of the jaw, which is 
painless, and gives him no trouble except from the deformity. 
The outer plate yields ordinarily to the pressure of the 
growing cyst, and thus a prominent smooth tumour is 
formed, over which the skin is freely movable. When the 
bony wall is sufficiently attenuated, the peculiar crackling 
already described may be produced on pressure, and if the 
disease is still unchecked the bone becomes entirely ab- 
sorbed, and nothing but a membranous cyst, with particles 
of osseous matter imbedded in it, remains. Of this a 
most remarkable specimen from a woman, at. forty-five, is 
to be seen in St. George's Hospital Museum (II. 150j. The 
cyst is for the most part single, and contains merely fluid, 
which may be clear or more or less coloured, Dupuytren 
narrates several cases of the kind ("Diseases of Bone," 
Sydenham Society, p. 437), from some of which only 
reddish-coloured serum escaped on their being opened, 
whilst in others a fibroid growth, and in one osseous nodules, 
were found within them. There is a good example of a 
single cyst for wliich a piece of the entire thickness of the 
lower jaw was excised in St. George's Museum, of which 
the following are the particulars : — The patient had had a 
tumour, supposed to be an epulis, removed from the same spot 



DENTIGEROUS CYSTS. 183 

two years before, and the disease had been growing since 
that time. When admitted the tumour was found to be a 
firm oval growtli, about the size of an orange, connected 
with the outer surface of tlie right inferior maxilla. It was 
evidently cystic, and there was an indistinct sensation of 
fluctuation. The tumour, as well as the portion of bone 
from which it grew, was removed by an incision in the 
median line. The extent of lower jaw removed was from 
the lateral incisor tooth on the left side to the angle of the 
jaw on the right. 

The accompanying drawings show a case of unilocular 
cyst of the lower jaw, for which Sir William Fergusson re- 

FiG. 79. 




moved a large portion of the bone. Fig. 79 shows the 
growth, and figs. 80 and 81 the patient before and after the 
operation. (See " Practical Surgery," p. 666.) 

Cysts in connection ivith undeveloped teeth, or Dentujerons 
Cysts (coronary cysts of Magitot) may occur in either jaw. 
These, as already mentioned, may suppurate and give rise to 
abscess, which may be confounded with suppuration within 
the antrum, or may project into the antrum, filling the cavity 
or communicating with it. 

Deutigerous cysts arise in connection with teeth which 
from some cause have remainad within the jaw, and have 
undergone a certain amount of irritation. They are almost 
invariably coimected with permanent teeth, though Mr. 
Salter mentions a case in connection with a temporary molar 



184 CYST IN THE LOWER JAW. 

Fig. so. 




Fig. 81. 




DENTfGEROUS CYSTS. 185 

occurring in the practice of Mr. Alexander Edwards, late 
of Edinburgh ; and in a remarkable specimen belonging to 
Mr. Cartwright, which will be afterwards referred to, the 
tooth is a supernumerary one. I have also myself met with 
an example of cyst connected with a temporary tootli in a 
boy of four years, brought to me by Mr. C. J. Fox. In this 
case the temporary right canine tooth was wanting, and there 
was a cyst developed in its situation, on cutting into which 
I extracted seven small irregular nodules of dentine and 
enamel, but no complete tooth, this being therefore an 
example of the odonto-plastic cyst of Magitot. 

My. Tomes explains the formation of cysts in connection 
with retained teeth by referring to the fact that when the 
development of the enamel of a tooth is completed, its outer 
surface becomes perfectly detached from the investing soft 
tissue, and a small quantity of transparent fluid not uncom- 
monly collects in the interval so formed. This fluid 
ordinarily is discharged when the tooth is cut, but when 
from some cause the eruption of the tooth is prevented, it 
increases in quantity, gradually distending the surrounding 
tissues in the form of a cyst. 

For further microscopic details and for a full discussion 
of Magitot 's views, I may refer to Mr. F. Eve's very able 
lecture on " Cystic Tumours of the Jaws," delivered at the 
Eoyal College of Surgeons, and pul)lished in the B/'it-ish 
Medical Journal, January 6, 1883. 

Mr. Salter, in his work on "Dental Pathology and Sur- 
gery," has collected several cases of dentigerous cyst, which 
were recognized and treated during life. Thus Jourdain 
records three cases, one in a girl of seventeen, in whom 
the first and second right upper permanent molars were 
inverted and the surrounding cyst had involved the antrum ; 
a second in a man of sixty, connected with a bicuspid tooth 
of the upper jaw ; and the third in a girl of thirteen, con- 
nected with an upper lateral incisor. Dupuytren and Bransby 
Cooper each met with a case in the upper jaw. Dupuytren's 
case, which was shown to him by M. Loir, being a remark- 
able instance of a cyst developed between the plates of the 



IS6 



DEXTIGEROUS CYSTS. 



palatine process of the upper jaw (.srr Diipnytren " On 
Diseases of Bone,"' Sydenham Society's translation, p. 438.) 

Professor Baum also met with an extraordinary case 
in a woman aged thirty-eight, both of whose antra were 
enormously dilated by cysts, from one of which a canine 
tooth, and from the other a molar tooth, was removed. ]\Ir. 
Salter gives two cases of his own, which will be found at 
length in the " Guy's Hospital Beports, 1859," one depend- 
ing upon the impaction of a wisdom tooth in the lower jaw 
of a man aged twenty-two, and the other in a girl of 
eighteen, who had an elastic fluid-containing tumour in the 
incisive region of the upper jaw connected with a permanent 
incisor tooth, tlie fang of wliicli was not developed, and whose 
place was occupied by a temporary tooth. 

Inversion of the tooth appears to be a frequent accom- 
paniment, or rather the cause of these cysts, and occurred 
in one of the cases narrated by Jourdain, and in those of 
Dupuytren and Bransby Cooper. Mr. Tomes ("Dental 
Surgery") has recorded a similar case in a girl of sixteen, 



Fig. 82. 










who had a swelling around the second molar tooth of the 
lower jaw, which proved to be a cyst. After being tapped, 
the cyst suppurated, and the extraction of the tooth became 
necessary, when the inverted crown of the third molar was 
found lodged between the expanded fangs of the second 
molar tooth, the two being united by dentine, and having 
one common pulp-cavity, as seen in the accompanying 
draM-ing, fig. 82, from Mr. Tomes' work. 

Cases of dentigerous cysts may be mistaken for solid 
tumours. Thus Gensoul, of Lyons, has recorded the case 
of a girl of thirteen, whose antrum was distended with a 



DENTTGEROUS CYST OF LOWER JAW. 187 

large collection of yellow fluid and contained a canine tooth 
attached to its wall, in whom he had made the incisions 
necessary for the removal of the tumour before he discovered 
its nature. Mr. Syme also has related {Edinhurgh Medical 
and Siorgical Journal, 1838) the case of a woman 8et. thirty- 
one, on whom he operated for a tumour of the upper jaw of 
four months' standing, by laying open the cheek and remov- 
ing the tumour with the bone-forceps. " The tumour was 
found to consist of a dense cyst lined throughout with earthy 
matter in a crystalline form, and containing a clear glairy 
fluidj together with the crown of a tooth, apparently the 
lateral incisor." In a cavity beyond the tumour was found 
a fully formed canine tooth, encrusted with a thin plate of 
bone. The teeth are said to have belonged to the tempo- 
rary set. 

When deutigerous cysts occur in the lower jaw they 
form more isolated and prominent tumours than in the case 
of the upper jaw, and in some cases the projecting bony 
wall has been removed. In St. Bartholomew's Museum 
is a specimen of the kind (I. 119), consisting of a portion 
of a bony cyst, which was removed by Mr. Earle from the 
external and lateral part of a lower jaw. The cyst is 
lined with a thick and soft membrane, which has been in 
part separated from it. The cavity of the cyst was filled 
with a glairy fluid, and at the bottom of it a canine tooth 
of the second set was adherent to the lining membrane. 
The case is referred to by Stanley, who gives an accurate 
drawing of the preparation. In the Museum of the College 
of Surgeons tliere is a very similar prei^aration (2196) 
showing a bony cyst of oval shape, one inch in its long 
diameter, lined with a thick well-formed membrane, con- 
taining an imperfectly formed bicuspid tooth, which was 
removed by Mr. Wormald from the lower jaw of a female 
aged seventeen, whose case will be found in the Lancet, 
June 22, 1850. 

When the cyst occurs in tlie lower jaw, and is less pro- 
minent than in the two cases already mentioned, giving rise 
rather to a general expansion of the bone tbnn a distinct 



188 



DENTIGEROUS CYSTS. 



tumour, the disease may be mistaken for a solid tumour of 
the lower jaw. A case of this kind occurred to that excel- 
lent surgeon, the late Mr. S. "\V. Fearn, of Derby, wdio 
had the courage and honesty to publish the case (British 
Medical Journal, Aug. 27, 1864), and to whom I was 
indebted for the very valuable preparation (College of 
vSurgeons IMuseum, 2195), from which the drawings, figs. 83 
and 84, were made. 

IVIr. Fearn's patient was a girl of thirteen, wdio had a 
large resistant tumour of the left side of the lower jaw, 



Fig. 83. 



Fig. 84. 




which had been growing six months. There was some 
enlargement also of the right side, and the teeth there were 
very irregular. The teeth on the left side had been ex- 
tracted, with the exception of the second molar and a tem- 
porary molar. Ko opening could be detected in the tumour, 
though there was a constant offensive discharge from its 
surface. Mr. Fearn removed the left half of the jaw from 
the symphysis to the articulation, and on division of the 
bone with the saw, a quantity of ftetid pus escaped. The 
tumour (fig. 83) proved to be a bony cyst formed by the 



DENTIGEROUS CYST OF LOWER JAW. 



189 



expansion of the two plates of the jaw, which extended for 
some distance to the right of the symphysis (a very unusual 
occurrence). The cavity is lined with a thick vascular 
membrane, and at the bottom the canine tooth will be seen 
projecting from the wall. The case was evidently therefore 
one of dentigerous cyst, due to the non-development of the 
canine tooth, the contents of which had, from some cause, 
become purulent. The mental foramen, with the nerve 
emerging, is still visible in the preparation and drawing (fig. 
81<). The patient made a good recovery. 

A very similar case is recorjded by Dr. Forget, in his 
essay on " Les Anomalies Dentaires et leur influence sur la 
production des Maladies des Os JMaxillaires," 1859, which 

Fig. 85. 




is translated by Mr. E. T. Hulme, in the Dental licviac, 
1860. The patient was a woman aged thirty, who had a 
tumour on the right side of the lower jaw, of the size of a 
hen's egg, extending from the lateral incisor to the base of 
the coronoid process, which had been growing ten years. 
M. Lisfranc removed half the jaw, and the patient made a 
good recovery. An examination of the tumour showed it 



190 



DENTIGEROUS CYSTS. 



to be a cyst, at the bottom of whicli lay the wisdom tooth, 
the crown projecting downwards into it, the fang being 
inverted and fixed in the base of the coronoid process. In 
the illustration (fig. 85), (for wldch I am indebted to Mr. 
Hulnie), the cyst has been opened, the internal wall, h, 
being left ; a marks the position of the tooth, and c the 
inferior dental canal, which has been opened to show its 
non-communication with the cyst. 

M. Legouest brought under the notice of the Societe de 
Chirurgie de Paris, in 186.2, a very similar case, which had the 
peculiarity of pulsating at one point synchronously with the 
radial pulse. The supposed tumour proved to be a denti- 
gerous cyst containing two teeth, the pulsation having been 



Fig. 86. 



Fig. 87. 





due to the great vascularity of the membrane covering it, 
and the great pain which had been experienced, to the fact 
that the dental canal was opened, and the nerve pressed 
upon by the cyst. {Gazette dcs Hopitaux, Aug. 7, 1862.) 

In the Annali Universcdi di Medicina for ]\Iay, 1867, Sig. 
Bottini, of Novara, has recorded a case of " subperiosteal 
and subcapsular disarticulation" of the left half of the 
lower jaw of a woman a:^t. twenty-three, for what proved a 
dentigerous cyst in connection with the wisdom tooth. 

Mr. Underwood has allowed me to have the accompany- 



DIAGNOSIS OF DENTIGEROUS CYSTS. 191 

ing drawing (fig. 86), taken from tlie model of a preparation 
which he possesses, showing very beautifully a cyst of the 
lower jaw, which was removed by M. Maisonneuve by saw- 
ing through the bone at two points. The canine tooth is 
seen lying horizontally at the bottom of the cyst. The 
patient, aged fifty-six, had a swelling in the lower jaw near 
the chin, and an opening formed behind one of his front 
teeth, from which a saline fluid escaped. The man made a 
good recovery from the operation. (Vide British Journal 
of Dental Science, 1862, p. 562). 

Dentigerous cysts, like other cysts, may undergo altera- 
tion, not only of the contents, but of the cyst-wall. The 
opportunities for recognizing such changes are exceedingly 
rare, and the only known specimen of the kind is one in the 
possession of j\lr. Samuel Cartwright, which shows calcifi- 
cation of the cyst-wall. The preparation (a reduced draw- 
ing of which (fig. 87) is taken from JMr. Catlin's paper on 
the Antrum) is one of the right superior maxilla, which, 
having been opened, shows a bony cyst within the antrum 
and attached to its floor, but unconnected with it elsewhere. 
The cyst has been opened, and contains a supernumerary 
tooth loose in its cavity, though no doubt originally attached 
to its base. This is clearly a case of dentigerous cyst which 
has undergone calcification, and which, had it been expanded 
to a greater degree before this change took place, would in 
all probability have been inseparably united with the walls 
of the antrum. 

The diagnosis of dentigerous cysts from other cysts is 
exceedingly difficult until they are opened, as indeed is the 
recognition of any form of cyst. A careful examination of 
the mouth may reveal the absence of a permanent tooth, or, 
as in one of Mr. Salter's cases, may show a temporary tooth 
occupying a permanent position, and this would direct the 
mind of the surgeon to the possible existence of a denti- 
gerous cyst. On the other hand, however, it must be 
remembered that teeth may be wanting without being con- 
nected with any disease ; thus I am acquainted with a family 
who have the hereditary peculiarity of a single bicuspid 



19- 



DENTIGEROUS CYSTS. 



tooth on each side. When a cyst is sufficiently expanded 
for the wall to yield under the finger witli the characteristic 
parchment-like crackle, there can he no difficulty in its 
recognition, but without this it is impossible in all cases to 
distinguish between a cyst and a slow-growing solid tumour. 
Under these circumstances, it is well to insist upon the 
propriety of making an exploratory puncture in all cases 
which are not obviously solid growths, and have sprouted so 
that their nature can be certainly recognized. The puncture 
being made within the mouth will be of no moment should 
a more severe operation subsequently be necessary. 

The accompanying engraving (fig. 88) shows a cyst of the 
lower jaw occurring in a man aged thirty-four, who was under 

Fig. 88. 




my care in 1 878, The swelling began nine years before, and 
was of the size of an ordinary orange, round, very hard, and 
fixed to the angle of the lower jaw on the right side. Its 
edges were well de lined, there was no lluctuation nor pulsa- 
tion, except that of the facial artery, which was stretched 



TREATMENT OF DENTIGEROUS CYSTS. 193 

over the tumour. Externally the tumour appeared to be 
solid, but examined from the mouth, the anterior part of the 
wall yielded slightly to firm pressure. On puncturing from 
the mouth through tlie bony wall I entered a large empty 
cavity lined with soft tissue, which on microscopical 
examination showed portions of hyaline cartilage and carti- 
lage with a faintly fibrous matrix, surrounded by and 
gradually passing into oval and sj)indle cells. The bony 
walls of the cyst were broken down and partially cut away, 
and this proceeding was repeated a fortnight later. The 
tumour gradually diminished as suppuration went on, 
several pieces of bone being removed, and, six weeks after 
the cyst had been opened, a tooth was felt fixed at the 
bottom of the cavity, and on being extracted proved to be a 
bicuspid with a perfect crown and two small fangs. After 
this the cavity closed and the swelling entirely disappeared. 
The case is remarkable, both for the age of the patient and 
also for the fact that the cyst was empty, the fluid which 
must have been present at one time having become absorbed. 
A careful search for a tooth was made at the time of the 
operation, but one could not be found, and its discovery at 
a later date was probably due to the destruction by suppura- 
tion of the lining membrane of the cyst, which had completely 
enveloped it. 

In the Museum of the Eoyal College of Surgeons is a 
preparation (2194) of the right side of the body of the lower 
jaw, completely and uniformly dilated into a large spherical 
cyst. No tooth or rudiment of a tooth can be discovered 
in the cyst, but its inner surface is lined by a layer of small 
epithelial cells and is thrown, in places, into thick project- 
ing folds. Mr. Eve considers it probable that the cyst 
originated in the enamel-organ of an abortive wisdom or 
supernumerary tooth, and hence would consider it an 
example of the follicular cyst developed in the embryonic 
period (Magitot). 

Treatment. — The treatment of dentigerous cysts is the 
same as for ordinary cysts — viz., a free incision ; and the 
subsequent extraction of the contained tooth. For the cure 

O 



194 DENTIGEROUS CYSTS. 

of many of these cases simple puncture will not suffice, and 
it will be necessary to remove a portion of the front wall of 
the cyst, and to fill the cavity with lint so as to induce 
granulation and gradual obliteration. This may be accom- 
plished in most instances without any incision of the integu- 
ments, and in a few more extensive cases by simply dividing 
the lip, and carrying the incision into the nostril. 

In cases where a permanent opening into the antrum is 
not required, it will be sufficient to turn up a sort of trap- 
door, as suggested by 0. Weber, the periosteum serving as 

Fig. 89. 




the hinge, so that it may be replaced after the removal of 
the contained cysts. It can but rarely happen that such an 
extensive mutilation can be requisite as is shown in a pre- 
paration in Gruy's Hospital Museum (1087), consisting of 
the outer wall of the antrum and the palatine plate, con- 
taining all the teeth of the left side except the central 
incisor, which was removed by Mr. Key from a case of very 
greatly distended antrum. 

In the case of dentigerous cysts of the lower jaw it will, 
after removal of a portion of the wall, be advisable to 
squeeze the plates together as far as possible, and in the 



TREATMENT OF DEXTIGEEOCS CYSTS. 11)5 

■case uf the upper jaw pressure by pads and baudaij^es, as 
recommended by Listnu, will do much to restore the parts 
to their usual form. Dr. Forget relates the case of a woman, 
of about thirty, with a liemispherical tumour of the right 
side of the lower jaw, \vhich was produce! by the bulging 
of tlie external plate of the ramus of the jaw, the internal 
having preserved its usual position. M. Xelaton exposed 
the tumour, and making a hole in the outer wall found a 
tooth projecting into the cyst. The tooth was extracted 
with some difficulty, and the patient perfectly recovered, and 
was well ten }ears after. The accompanying illustration, 
(fig. 89^, represents the relation of the parts, h pointing out 
the position of the tooth. {Dental Ecvicic, 1860.) 

The cyst should always be reached by dividing the nnicous 
membrane within the mouth, and without incising the cheek ; 
but if necessary, a single line of incision only should be made^ 
so that as little after-deformity as j)ossible may be produced. 



O 2 



196 



CHAPTEE XIII. 

CYSTS OF LOUVER JAW — MULTILOCULAE CYSTIC TUMOUR. 

During the last few years very considerable light has been 
thrown upon the clinical history and pathology of certain 
cystic tumours of the jaws, both by cases occurring in my 
own practice, and by the careful microscopic investigation of 
these and others by Mr. Frederick Eve, who embodied his 
results in a lecture given at the College of Surgeons in 1882, 
and published in the British Medical Journal of January 6, 
1883. Believing that Mr. Eve's views are confirmed by 
clinical experience, I have adopted them in the following 
pages, and shall include, under the head of " multilocular 
cystic tumour," several tumours whicli in former editions of 
this work were classed as " cystic sarcoma" — always an 
unsatisfactory term — as well as those hitherto regarded as 
simply multilocular cysts. 

Mr. Eve believes that so far from multilocular cysts having 
a dental origin, they are produced by an ingrowth of the 
epithelium of the gum. They have frequently followed some 
form of injury, irritation by decayed teeth, or long-continued 
inflammation, which has induced an increased supply of 
blood to the parts. The multilocular cystic tumours are 
slow of growth, they have very little tendency to implicate 
surrounding parts or the neighbouring lymphatic glands, and 
if completely removed rarely recur and still more rarely 
become disseminated through the system. Their comparative 
innocence is probably explained by the bony capsule forming 
their boundary, by their low degree of vascularity, and by 
the remarkable tendency of the ei^ithelial cells composing 
them to undergo degenerative changes. 

Multilocular cysts may contain other cysts within them. 



MULTILOCULAR CYSTS. 197 

but this condition must be a rare one, for I can find only 
two examples of it. One is a congenital cystic tumour in 
an infant of six months, who was under Mr. Coote's care in 
1861, and of which the following brief facts are extracted 
from the Lancd of Aug. 31, 1861: — "The right half of 
the lower jaw was enormously enlarged, and occupied a 
prominent position in the neck, extending downwards as far 
as the chest. It appeared to invade the entire bone, but 
was really confined to the right side. Its increase had been 
rapid since birth, and as it was still enlarging it became 
necessary to do something to afford a chance for life, as, if 
left alone, suffocation would have ensued in a short time. 
Accordingly, chloroform being given, an incision was made 
by Mr. Coote upon its outer part, and a thin shell of the 
expanded jawbone reached. This was opened, and the 
interior was found to be filled with a regular nest of cysts, 
one placed within the other, all of wdiich were removed, and 
the cavity closed with lint. Very little blood was lost 
during the operation, and for a few days afterwards the child 
improved very much in health, although necessarily weak, 
and the great swelling of the neck was much diminished. 
Suppuration became freely established, and the drain shortly 
after began to tell upon the system, for the child became 
weaker and weaker, although well supplied with wine and 
good nourishment, and finally died from exhaustion." 

The other instance is given by Mr. Syme {Lancet, March 
10, 1855), who quotes the case of a woman having a large 
cystic tumour of the lower jaw, in whom he three times 
opened the cyst and stuffed it, with temporary benefit. He 
was obliged eventually, however (five years after the first 
operation), to remove one-half of the bone, when the cyst 
was found to be compound, there being four cavities, the 
walls of which were studded with smaller cysts. 

Multilocular cysts are more often found in the lower than 
in the upper jaw, and in most cases in direct connection 
with teeth or stumps. In the Guys Hospital Reports for 
ISl? is the notice of a case of the kind by Dr. Wilks, in a 
girl of eighteen, in whom there had been an enlargement of 



1.98 CYSTS IX THE LOWER JAAV. 

the right side of tlie lower jaw for twelve years. The 
tumour, on removal, proved to be a cystic growth : " there 
being four or five large cells between the internal and external 
plates of bone, which appeared like expanded alveoli, all of 
them containing fangs of teeth. The cells contained a glairy 
fluid." Very considerable alteration in the form of the 
maxilla may be produced by gTOwths of this kind, of which 
a good example is seen in the drawing (fig. 90) from a 
macerated specimen in St. Bartholomew's Museum (I. 308.) 

Fig. 00. 




Here the bone is irregularly expanded in great part, to form 
septa between cysts. These^ which Avere independent of one 
another, had their origin in the interior of the bone, were 
lined by a highly vascular membrane, and contained thin 
serous, or grumous, blood-tinged fluid. The walls of some of 
the cysts were thin and yielding, but others were thick and 
resisting, and this was particularly the case with the most 
posterior cyst on the left side, wdiich had pressed upon and 
caused absorption of the left ramus and coronoid process. 



SKELETON OF CYSTS. 199 

The preparation was taken after death from an okl man 
aged seventy-five, who had noticed the enlargement for five 
years when he came under Mr. Coote's care in St. Bartho- 
lomew's Hospital in 1857. The following brief account of 
the case is taken from the Lancet of Oct. 10, 1857 : — 
" The origin of the affection Mr. Coote attributed to the 
irritation produced by the stumps of decayed teeth. He 
punctured some of these cysts with a trocar, and gave exit 
to a sero-purulent fluid from one, and fluid like the white 
of egg from two others. On the 5th of September he pulled 
out a couple of bodies of teeth, with scarcely any remains of 
fangs, but in their stead some irregular fibrous-like projec- 
tions. The removal of these permitted the flow of a sero- 
albuminous fluid, the teeth having acted like stoppers. Since 
the man had been in hospital, the size of the tumour had 
most certainly diminished one-third under the plan of treat- 
ment of puncturing. The age of the patient precluded the 
possibility of attempting any more severe measures than 
those already adopted. On the 21st the swelling had some- 
what increased, and three or four of the cysts were again 
punctured, with the discharge of a thick, clear, yellow fluid, 
and several of these were run into one internally. This was 
done under partial anesthesia from chloroform. One of the 
cysts discharged a good deal in the mouth ; this was partly 
swallowed, and had caused indigestion." 

In St. Mary's Hospital Museum is a valuable recent 
specimen (A. d. 50) of the same disease, removed by Mr. 
Lane. Here the growth was of seven years' duration, and 
involved the left side of the body of the lower jaw. A 
longitudinal section shows the cystic structure, the cells of 
which were filled with dark gelatinous fluid, and occupied 
the whole thickness of the bone. 

The cells may, however, be of much smaller size ; thus 
Dr. Robert Adams records, in the DuUin Hospital Gazette 
for 1857, the case of a man ^rom whom he removed a por- 
tion of the body of the jaw from the symphysis to the molar 
teeth, about two inches in length. " The mucous membrane 
covering it was here and there raised into small rounded 



200 



CYSTS IN THE LOWER JAW. 



eminences of the size of peas, though some were larger and 
purple in colour (fig. 91). The tumour was composed of bony 
cells of a texture as fine as the ethmoid bone. The cells 
generally were of such a size that each might be capable of 
receiving witliin it a garden pea. They communicated widi 
each other, and amounted to no less than twenty-six in 
number. They were all lined by a pulpy, very red, vascular 
membrane, and contained an albuminous fluid tinged of a 
reddish colour, apparently from blood held dissolved in it." 

Fig. 91. 



B 




A, Canine ; b, Second molar ; c, Anterior portion of dental nerve ; 
D, Remains of the base of horizontal branch of jaw excavated ou its 
upper surface, on which lay the tnmonr. 

Again, in cases of long-standing disease the cysts become 
greatly distended, and the septa, in great part, absorbed, so 
that the cysts communicate very freely. 



MR. CUSACKS CASE. 



201 



Of tliis kind was a tumour (tig. 92) removed by Mr. Cusack, 
in 1826, from a woman named Kenny, whose case will be 
found in detail in Mr. Cusack's well-known essay in the 
Dublin Hospital Bcports, vol. iv. Dr. Adams, in his paper 
already referred to, supplies an account of the tumour in 
this case. " The portion of bone removed comprises the 
entire right half of the lower jaw. The horizontal ramus is 

Fig. 02. 




expanded into an oblong hollow shell with bony walls, and 
its interior is subdivided into many cells of various sizes, 
which are all lined by a fine polished membrane, and com- 
municate freely with each other." 

The microscopic character of the solid material found 
more or less in all cases of multilocular cyst is well given in 
the following report by Mr, Eve upon a very well-marked 
recent specimen of the disease, contributed to the St. Bartholo- 



202 MULTILOCULAR CYSTIC TUMOUE. 

mew's Hospital Museum (1.536) by Mr. Keetley: — "Tliu solid 
portion of the tumour was composed of columns of cells and 
nuclei of the epithelial type, which, when cut transversely, 
presented the appearance of alveoli ; similar small columns 
branched out from the side of the larger. The cells in the 
centre of the columns had in many places undergone a colloid 
change, and by the complete metamorphosis of the cells the 
cysts were formed. From the buccal mucous membrane 
covering the tumour, in certain parts, club-shaped and branch- 
ing cylinders extended down from the deep stratum of the 
epithelium, as in the ordinary formation of epithelial cancer." 
Mr. Eve has found precisely the same characters in twelve 
specimens of multilocular cystic tumours he has examined, 
one of the most marked being a tumour of the vppcr jaw 
removed by i\Ir. Liston in 1836, and referred to in his paper 
in the Medico-Chirurgical Trcaisactio'/is, vol. xx., the tumour 
being now in the College of Surgeons' Museum (2202). 

To show the identity of the foregoing with the tumours 
hitherto classed as " cystic sarcomata," I may quote the 
description of the microscopic appearances of a tumour of 
the latter kind removed by myself, in 1871, from a patient 
fet. twenty-two, whose portrait before and after the operation 
is given in figs. 93 and 94, and whose case will be found 
in detail in the Appendix (Case IX.) : — " The tumour was 
composed microscopically of straight or tortuous columns of 
epithelial cells, those forming the margin being elongated or 
cylindrical and radiating towards the centre. At the margin 
of the small ulcerated opening in the gimi, papillary processes 
extended downiiwards from the deep stratum of the epithelium, 
and were continuous with the colimins forming the tumour" 
(College of Surgeons' Museum, 2203), The half of this 
tumour, deposited in the Museum of University College, is 
described in the valuable catalogue by Mr. Marcus Beck as a 
" gland-like tumour of bone," and its structure is identical 
with that of a tumour described by Mr. Wagstafie in the 
Pathological Society's Transactions, vol. xxii. Mr. Wagstaffe 
found that the growth was composed of innumerable cysts 
and a solid matrix, through which a certain amount of bone 



CYSTIC SARCOMA. 



203 



was scattered ; that the cysts were lined by a layer of large 
globular epithelium ; that into the interior of the larger cysts 
other smaller cysts projected, and these endogenous cysts 
took their origin in the epithelial lining, and not in the 
matrix of the growth. Other cysts were also freely scattered 
throughout the structure, but the endogenous formations 
were so marked that they could be discovered as little balls 
by the naked eye, and removed for examination by the point 
of a needle. The solid structure consisted of a. very peculiar 



Fk;. 93. 



Fir;. 04. 




arrangement of wliat appeared to be acini or cylinders of 
closely -packed cells, supported by a fibro-nucleated matrix. 
These acini, or rods, in many places gave the appearance of 
tubes from the arrangement of their component cells, which 
resembled very curiously that of columnar epithelium, or of 
the epithelimii of gland follicles. The cut ends, however, 
showed no central canal. The constituents of these rods 
were nuclei embedded in plastic matter, and these separated 



204 



MULTILOCULAR CYSTIC TUMOUR. 



by manipulation into small tailed or so-called spindle cells, 
of similar size and character to the corpuscles of an ordinary 
sarcoma. 

The best example of the disease, hitherto KnoWii as cystic 

Fi(!. n.'). 




sarcoma, with which I am acquainted, is in the JMuseum of 
the Eichmond Hospital, Dul)lin, and was removed by the 
late Dr. Hutton. It is represented in the accompanying 
woodcut (fig. 95), for which I am indebted to Dr. Pi. Adams, 



MULTILOCULAR CYSTIC TUMOUR. 205 

and shows very beautifully tlie development of cysts of 
various sizes in a growth of a benign cliaracter, involving 
the whole of one side of the body of the jaw and extending 
to an inch beyond the symphysis. The patient was a young 
woman of twenty, and the tumour had existed nine years, 
but had only recently made rapid progress, and produced 
great distress by its pressure on the tongue and mouth. Dr. 
Hutton removed the jaw from the right of the symphisis to 
the left angle, and the patient made a good recovery {Dublin 
Hospital Gazette, 1860). In this case the disease invaded 
only the body of the bone, but the ramus is also liable to it, 
a specimen in King's College Museum, removed by the late 
Mr. J. H. Green, being an instance in point. 

The contents of these cysts vary in consistency and colour ; 
in some cases being clear and limpid, in others almost 
gelatinous and of a dark colour. 

My attention was first directed to the fact that multi- 
locular cystic disease is not always a simj)le local ailment, 
by the case of a patient who was able to give me a " Thirty- 
five years history of a maxillary tumour," which I communi- 
cated in 1880 to the Association of Surgeons practising Dental 
Surgery {British Medical Journcd, May 22, 1880). The 
patient, when he first came under my notice in 1877, was a 
healthy country gentleman, who said that, as long as he could 
remember, there had been some enlai-gement of the right side 
of the lower jaw. In 1845 this enlargement increased very 
rapidly, and in 1847 Sir W. Fergusson removed a tumour 
of the right side, sawing through the ramus horizontally, and 
the body of the jaw close to the right canine tooth. The 
tumour was apparently of a fibroid character, having a large 
cyst developed in it, and is now in the Museum of King's 
College. He continued in good health for fifteen years, and 
then noticed the formation of a cyst in the incisor region, 
which had frequently been tapped by Sir W. Fergusson. 
In July, 1877, I found cystic disease of the left side of the 
body of the jaw extending to the molar region, and operated 
by extracting all the teeth, opening up the cysts freely, and 
clearing out some solid growth with tlie gouge. From this 



206 MULTILOCULAR CYSTIC TUMOURS. 

the patient made a good recovery, with considerable con- 
solidation of the hone, but, in the following November, one 
cyst was found to have developed anew in the incisor region, 
and this was treated in a similar manner. A year later a 
fresh development of cysts had taken place and the operation 
was repeated with a good result, so that in February, 1879, 
the jaw was completely consolidated, and the patient was 
advised to have some artificial teeth fitted. In November, 
1879, the patient reappeared with a large solid tumom*, in- 
volving the left side of the body of the jaw, which, noticed 
first in June, had grown rapidly of late, and now invoh'ed 
the skin for an area of a square inch. On December 2nd 
I removed the tumour by sawing through the bone immedi- 
ately in front of the left masseter, and also removed a j)iece 
of infiltrated skin from the left of the median line. The 
wound was brought together with harelip-pins and sutures, 
and only one artery (facial) was ligatured. The patient 
made a good recovery, took food with a spoon, and was able 
to talk intelligibly after the first week, although deprived 
now of the entire body of the jaw. The lower end of the 
wound being left open afforded a thorough drain for discharge. 
The patient returned early in February, when the skin near 
the wound was found to be increasingly infiltrated, and a 
tumour of the size of an orange was found beneath the right 
deltoid. He had strained the right arm in getting into a 
hip-bath, but was quite clear that the humerus had not been 
struck. The tumour was painful, but the bone w'as sound, 
the head moving with the shaft. A week later the patient 
was found to have a tumour in the pelvis, pressing upon the 
rectum, and springing from the interior of the right innomi- 
nate bone. From this time he gradually lost strength, and 
died at the end of March. The second tumour was pronounced 
by Mr. Doran to be a round-celled sarcoma, and the same 
growth was found in the piece of skin which was removed. 
The earlier tumour appeared to be a fibroid or a spindle-celled 
sarcoma. No post-mortem examination of the internal 
growths could be obtained. 

The specimen is preserved in the Museum of the College 



MULTILOCULAR CYSTIC TUMOUR. 207 

of Surgeons (2204), and Mr. Eve's further examination con- 
firms the fact that the bulk of the tumour is round-celled 
sarcoma, but in addition the upper portion of the tumour 
contains isolated masses composed of tortuous closely- 
crowded columns of small epithelial cells. 

The second case bearing upon the same question was in a 
woman of forty-four, who w^as admitted into University 
College Hospital, on November 3, 1875, with the following 
history : — About nine years before, the patient first noticed 
a lump of the size of a pea beneath the tongue, on the right 
side, which gave her some pain, and for which a tooth was 
extracted. From that time she had a succession of ab- 
scesses (?) in the lower jaw, some of which discharged in tlie 
mouth, and one externally, and for which she had had several 
teeth extracted. Dr. Parsons, of Dover, had sent her to me 
three years before, and I then recommended her to come 
into the hospital ; but she declined, and went on with a 
steadily increasing tumour of the lower jaw on the right 
side. About nine months before admission the tumour 
seems to have begun to increase with some rapidity, and 
within the last two months, the following characteristic 
event happened. While eating, the ]3atient felt a sudden 
crack in the lower jaw, and this occurred twice in the same 
week ; and upon each occasion she felt great j)fiiii in the 
floor of the mouth and upon moving the tongue. Upon 
admission there was really very little to be seen externally, 
and a photograph taken at the time shows that, excepting a 
very small projection beneath the skin in front of the angle 
of the jaw, there was nothing to call attention to the patient's 
face. On looking into the mouth, however, the tumour was 
at once obvious, and is seen in a cast taken from the jaw at 
that tune (fig. 96). The right side of the lower jaw is seen 
to be greatly expanded from immediately in front of the 
ramus to beyond the median line, the tumour measuring 
two inches across at the broadest part, and reaching under 
the tongue. Its surface was lobulated and rounded, firm 
and osseous in tlie gi^eater part, but yielding distinctly on 
pressure in two or three places. The mucous membrane 



208 TUMOURS OF THE LOWER JAW. 

was entire over the tumour, except at one point where there 
was an opening, from which a discharge constantly exuded. 
The incisor teeth of the right side were displaced over to the 
opposite side, and were loose. Tlie central incisor of the 
left side was displaced completely in front of the other teeth. 
The left canine and bicuspids were firmly fixed. ISTotwith- 
standing the size of the tumour, the outline of the lower 
border of the jaw was scarcely interfered with, the disease 

Fio. 9G. 




being mainly confined to the alveolar portion of the bone ; 
and I, therefore, decided to operate from within the mouth, 
so as to avoid, if possible, all external scar. 

On November 10 the patient was put under chloroform, 
and, a gag having been introduced on the left side, I first 
extracted the four incisors, and then made a free incision 
with a stout scalpel along the upper surface of the tumour, 
cutting easily through the thin bone and thick membrane 
forming its upper wall. A quantity of dark-coloured cystic 
fluid at once escaped, and I then cleared out the semi-solid 
contents with the fin£rer and gouge. The finger introduced 



MULTILOOULAR CYSTIC TUMOUR. 



209 



into the cavity passed completely under the canine and 
bicuspid teeth of the opposite side without disturbing them. 
I next cut away a portion of the cyst- wall with scissors, and 
crushed together the remainder, as far as I could, with my 
fingers and thumb. The actual cautery was applied to one 
spouting vessel in the margin of the alveolus, and the cavity 
was stuffed with lint dipped in a solution of chloride of zinc 
(twenty grains to the ounce). 

The patient had very little constitutional disturbance ; the 
plugs were gradually removed from the cavity of the jaw, 
which was carefully syringed out frequently with Condy's 
fluid, and soon began to granulate and fill up. She 
was discharged a month after the operation, when the two 
plates of the lower jaw had come together, and the cavity 
was filled up almost completely by granulation-tissue, there 
being only a shallow cavity half an inch long still to be 
filled up midway between the angle and the symphysis. 

Fig. 97. 




This patient again f)resented herself in October, 1878, nearly 
three years after the first operation, with a recurrence of the 



210 



MULTILOCULAR CYSTIC TUMOUR. 



cysts,Avliicli were treated again by gouging and crusliing in. In 
August, 1882, she again appeared with a formidable tumour 
of the lower jaw, which had already sprouted through the 
chin at more tlian one point (fig. 97). There could be no 
question Yn>\y of the necessity for excising the portion of 
jaw involved, and this I accordingly did, removing from an 
inch in front of the amrlc on the left side to the right temporo- 
maxillary articulation. The patient made a good recover}', 
and has remained well. 

Fui. 9^. 




The occurrence of solid epitheliomatous growths, as a 
sequel of multilocular cystic disease, being now^ sufficiently 
illustrated, I may refer again to the case of " cystic sarcoma" 
described at p. 202, and illustrated by figs. 93 and 94. It will 
be found on referring to the details of the operation (Case IX.), 
that I left m situ the coronoid process and condyle with 
part of the posterior border of the lower jaw, in June, 1872. 
In October, 1883, this patient reappeared in the condition 
shown in fig. 98, with a typical epithelial ulcer of the skin 
of the cheek. On proceeding to cut this away freely, I 



TREATMENT OF CY8TS IN LOWER JAW. 211 

found that it was attached to the remains of the lower jaw, 
which I was obhged to remove in order to get rid of the 
whole of the growth. One half of this secondary growth is 
in the Museum of the College of Surgeons (2203A), and its 
microscopic characters correspond precisely to those of the 
former growth, p. 202. 

There can, then, I think, be no doubt that under the term 
" multilocular cystic epithelial tumour," as proposed by Mr. 
Eve, we may include the old multilocular cysts and cystic 
sarcomata, both having a distinct tendency to be reproduced 
locally, and in certain cases to become disseminated. 

Treatment. — Mr. Butcher, of Dublin, has for some years 
treated cases of multilocular cyst of the lower jaw through 
the mouth, by dividing the mucous membrane over the cyst 
freely, and then with gouge and bone-forceps removing the 
expanded external plate of the bone, with the contents and 
lining membrane of the cyst. In this operation, the teeth 
are interfered with as little as possible, and appear to remain 
firm. Granulations rapidly spring up from the denuded 
bone, and fill the wound made in the mouth ; the cheek 
resumes its ordinary appearance, and no deformity or scar is 
left. In his work on " Operative and Conservative Surgery," 
Mr. Butcher narrates three cases treated in this manner, 
and remarks, that " the proceeding according to this j)lan is 
troublesome and difficult, but its value to the patient in 
having no deformity left is priceless." A valuable caution is 
here given respecting the facial artery, which might, without 
care, be divided from within the mouth in a position where 
it would be very difficult to secure it. Mr. Butcher also 
narrates and gives a drawing of a case in which, finding the 
disease too extensive to be treated from the mouth, he 
adopted Dupuytren's external incision, and then levelled the 
projection to the line of the healthy bone with the best 
results, the incision being completely hidden behind the 
bone. 

Dr. Mason Warren has also {Boston 3fcclical and 
Surgical Journal, 1866) written upon the treatment of cysts 
of the jaws, and strongly recommends a milder and even 

P 2 



212 MULTILOCULAR CYSTIC TUMOUR. 

more conservative practice tlian tliat followed by Mr. 
Butcher, which he thus summarizes : — " The treatment con- 
sisted in the puncture of the sac within the mouth, evacuating 
its contents, and at the same time obliterating its cavity by 
crushing in its walls ; and lastly, in keeping up, by injec- 
tions, &c., a sufficient degree of irritation to favour the 
deposition of new bone." 

I have now treated a considerable number of simple and 
multilocular cysts by ]\Ir. Butcher's method, and, as has been 
noted, with recurrence in at least two of the latter. Mr. 
Butcher does not appear to have met with further trouble in 
his cases, and this may depend upon his " carrying out the 
gouging fearlessly and far wide of the disease." I should in 
future be guided by the age of the patient, and the amount 
of solid material found in the cysts. In young persons with 
cysts having fluid contents and little growth in the bone, I 
should be still inclined to adopt palliative measures and to 
gouge very freely, carefully watching the case with a view 
to a more radical proceeding, should further development take 
place. In cases of much solid deposit in connection with 
multilocular cysts, and still more in cases of solid tumour 
with one or more large cysts, there should, I think, be no 
doubt as to the removal of one-half or more of the lower 
jaw, or of any portion of the upper jaw involved. 

In his well-known essay on "Diseases of the Jaw" (Calcutta, 
1844) Mr. O'Shaughnessy narrates a case of large cystic 
disease of the jaw which would appear to have been 
originally a multilocular cyst, in which the septa had under- 
gone almost complete absorption, so that " the tumour after 
maceration was found to be a hollow shell of bone, con- 
taining in its centre a quantity of a gelatinous and fluid 
substance, and a few particles of bone like pieces of honey- 
comb. The coronoid process was hollowed out like the rest 
of the bone, and so thick, that it must have completely 
filled the temporal fossa, which accounts for the difficulty 
experienced in trying to divide the temporal muscle." 

This difficulty of clearing the coronoid process has been 
noticed also in cases where the bone has been expanded by 



CYSTS IN THE LOWER JAW. 213 

a solid growth within it, or is wedged in by a portion of 
tumour springing from the ramus. Dr. Eobert Adams 
narrates {Dublin Hospital Gazette, April 15, 1857) a case 
of the former kind, and Mr. Cusack {Duhlin Hospital Reimrts, 
vol. iv.) two cases of the latter, in all of which the difficulty 
was overcome by sawing through the ramus of the jaw and 
subsequently removing the coronoid process and condyle. 
The possible occurrence of this difficulty is to be borne in 
mind in cases of cystic growth requiring disarticulation ; 
and I experienced it in the case of large " cystic-sarcoma," 
already referred to. 

The difficulty is best got over by the division of the 
coronoid process with the bone- forceps, and the piece thus 
cut oif should afterwards be dissected out. 



214 



CHAPTEE XIV. 

TUMOLRS CONNECTED AVITH TEETH AND ODONTOMATA. 

Irregular developmeut of the teeth is of little interest from 
a surgical point of view, except when, from their abnormal 
positions, they give rise to tumours of the jaw. The rela- 
tion of cysts to undeveloped teeth has been discussed under 
the head of " Dentigerous Cysts," but the solid growths 
directly connected with the teeth also require investigation. 

The iiTegiilarities of the teeth which are fully cut come into 
the province of the dental surgeon, and in Mr. Tomes' 
valuable work on Dental Surgery, numerous drawings are 
given of the abnormal positions in which various teeth have 
appeared. It is the uncut teeth, however, which are of 
interest surgically, and these may be divided into two 
classes. In the first, the tooth which has deviated from its 
normal position is still contained within the alveolus, where 
by its presence it may give rise to a more or less distinct 
tumour. Of tliis fig. 99 gives an example from the work 
of Dr. Foi'get, on Dental Anomalies, for permission to use 
which I am indebted to Mr. E. T. Hulme, the translator of 
Dr. Forget's papers in the Dental Bevicw of 1860. In the 
second class of cases the misplaced tooth is situated in a part 
of the jaw more or less distant from the alveolus, and of this 
fig. 100 presents an example, the canine tooth being placeil 
horizontally in the floor of the nasal fossa, in the interior of 
which it formed a considerable projection. 

The molar teeth of the upper jaw, and particularly the 
wisdom teeth, seem especially liable to misplacement. Mr. 
Tomes (o^j. cit.) gives numerous illustrations of this irre- 
gularity, and in the Museum of the College of Surgeons is 



MISPLACED TEETH. 



215 



a cast of a case in which a wisdom tooth projected through 
the clieek. The wisdom teeth of the lower jaw are also 



Fig. on. 




prone to assume an abnormal position in relation to the 
coronoid process, and in either position a tmiiour may be 



Fig. 100. 




216 TUMOURS CONNECTED WITH THE TEETH. 

formed which may be difficult of diagnosis. Dr. Forget 
{op. cit.) quotes the case of a woman who hadj on the left 
side of the hard palate, a tumour of the form and size of 
a nut, which reached beyond the median line, and extended 
from the canine tooth to the soft palate. Blandin, on at- 
tempting to remove it, discovered it to be caused by two 
dwarfed and abnormally-placed molar teeth, which had pene- 
trated the inner plate of the alveolus, and were lodged be- 
neath the mucous membrane of the palate. On the removal 
of these the tumour subsided. A similar case of tumour of 
the palate, due to a molar tooth, is recorded in Tomes' " Dental 
Surgery." Still more remarkable is the case narrated by 
Mr. Tellander, of Stockholm, before the Odontological Society, 
in December, 1862, of supernumerary teeth imbedded in 
the upper jaw, causing a hard painless tumour, which 
appeared about the age of twelve ; and this again is eclipsed 
by the case recorded by Mr. Tomes, which occurred in the 
person of a Hindoo, aged twenty-five, who suffered from a 
large tumour of the front of the upper jaw. Mr. Mathias, 
under whose care the man was, removed fifteen masses of ill- 
formed and supernumerary teeth ("Dental Surgery," 2nd ed.). 
It is possible, however, that both these last cases may have 
been examples of dentigerous cyst which had ruptured before 
the patient came under observation, resembling the case of 
cyst with nodules of dentine mentioned at page 185. 

The crown of a temporary tooth, of which the fang has been 
absorbed, may be so crowded in by its permanent neighbours 
as to disappear within the alveolus and give rise to irritation 
and anomalous symjjtoms. I was once consulted in a case 
of this kind, when Mr. Edgelow skilfully extracted from 
some depth the temporary crown, which proved to contain 
a stopping ! 

But the malposition of a tooth may give rise to a dense 
osseous tumour of the upper jaw, in which it is impossible to 
recognize the source of mischief until after removal of the 
tumour. Of this kind was a case which occurred to Sir 
William Fergusson, in 1856, in a girl aged thirteen, in 
whom for three years there had been growing a dense 



ODONTOMATA. 217 

tumour of the left superior maxilla, which, upon section 
after removal, proved to contain a tooth imbedded in its 
centre. 

Even more remarkable, however, than mere malposition, 
are certain modifications which the molar teeth occasionally 
undergo during their development, giving rise to most 
interesting tumours of the jaw, which have been specially 
studied and described under the name Odo7itomcs by M. 
Broca (" Traite des Tumeurs," 1869). These tumours depend 
upon some modification of the germ of the tooth before the 
formation of the cap of dentine, and belong to Broca's second 
class, odontomes odonto-plastiques or odontomcs hidhaires. 
The result is the formation of an irregular mass of dental 
tissues in no way resembling a tooth in shape. 

There are, I believe, but eight cases of this form of 
odontoma recorded, and these all occurred in the lower jaw. 
The first case was communicated to the Faculty of Medicine 
of Paris in 1809 by M. Oudet. The patient, a man aged 
twenty-five, had on the right side of the lower jaw a mass 
occupying the position of the premolar teeth, which on 
removal proved to be composed of dentine and enamel. 
A similar mass on the left side was not removed. The 
second case occurred some years back, in the practice of 
Sir William Fergusson, by whom the tumour was removed 
with a portion of the jaw, and is described by Mr. Tomes 
(" Dental Surgery"), from whose work a drawing of a section 
of the tumour is taken (fig. 101). " The second molar of 
the lower jaw was represented by an irregularly flattened 
mass, composed of enamel, dentine, and bone derived from 
calcification of remnants of the dentine i^ulp, thrown together 
without any definite arrangement, by wliich tlie wisdom 
tooth was held down. The dental mass, when removed 
from its receptacle in the bone, presented no resemblance to 
a tooth. Little beads of enamel here and there projected 
from the surface, which was generally rough and irregular. 
The naked-eye appearance of the section is accurately given 
in the woodcut, the radiate character in which shows the 
arrangement of the component tissues, which, by the aid of 



218 ODONTOMATA. 

the microscope, are seen at places to alternate. The 
alternation is mainly effected by the dentine and bony tissue, 

and these, indeed, form the great bulk of the mass 

The appearances presented, prior to the operation, consisted 
in enlargement of the jaw posterior to the first permanent 
molar tooth, witli a hard, brown-looking body projecting but 
slightly from the surface of the gum. This projecting 
portion was, in fact, the upper surface of the aberrant tooth ; 
and the nodules of enamel were, for the most part, situated 
in this part of the mass. 

The third case occurred to Dr. Forget {op. cit.), in the 
person of a young man, aged twenty, who presented himself 

Fig. 101. 




in 1855 with a disease of the lower jaw, from which he had 
suffered since he was five years old. Upon looking into the 
mouth, a round, smooth tumour, hard and unyielding, was 
seen occupying nearly the whole of the left side of the jaw. 
None of the teeth beyond the first bicuspid were present. Dr. 
Forget removed the portion of the jaw involved by sawing 
through it in front of the bicuspid tooth, and also through 
the ramus at the level of the inferior dental foramen. Tlie 
portion removed is seen in the accompanying drawing (fig. 
102). An examination of the portion which had been re- 
moved, showed that the portion of the jaw between the 
ramus and the first bicuspid tootli was converted into a cavity, 



ODONTOMATA. 



219 



wliich was occupied by a hard oval mass, of the size of an 
eo-o- having an uneven surface covered here and there with 
minute tubercles, which were invested by a layer of enamel, 
penetrating into the substance of the bone, and easily recog- 
nizable by its shining appearance and peculiar colour. A 
section of the tumour showed that it consisted of a compact 
tissue of tlie consistence of ivory, of a greyish-white colour, 
in the interior of which it was possible to perceive, with the 
naked eye, a kind of regular arrangement of the elements 
wliich entered into its composition. Between the tumour 
and the osseous cyst was a thick membrane, a])parently of a 

Fkj. 102. 




tibro-celhdar structure. At the anterior extremity of the 
base of tlie tumour was a depression in whicli the crown of 
an inverted molar tooth was wedged in between it and the 
maxilla. This tooth is seen in fig. 102, c, where a portion of 
bone has been cut away ; a and h mark portions of the 
tumour projecting through the jaw, and d is the second liicus- 
pid tooth lying below the first, e. 

The microscopic examination of the tumour showed it to 
be composed principally of dentine, with enamel on the sur- 
face and dipping into the crevices, at the bottom of which, 
as well as in otlier parts, portions of cementum were found. 



220 ODONTOMA TA . 

Dr. Forget regards Llic ease as one of fusion and liypertropby 
of the last two molars. 

The fourth case of the kind was brought under the notice 
of the Odontological Society of Great Britain, in December, 
1862, by the late Mr. W. A. Harrison, F.E.C.S. The 
specimen closely resembled those already described, and 
came from the left side of the lower jaw of a lunatic, where 
it occupied the space between the incisor and molar teeth. 
It came away spontaneously, leaving a long deep groove, 
large enough to receive the last joint of the tlumib, which 
soon granulated and contracted. The specimen is in the 
Museum of the Dental Hospital, Leicester Square. Cases 
of a similar kind have been met with in the lower animals, 
especially the horse. (British Journal of Dental Science, 
December, 1862). 

The fifth case is gi\^en in Heider and Wedl's Atlas zur 
Fatholor/ie der Zdlinc, and closely resembles Mr. Tomes' case, 
the second molar tooth of the right side being developed 
into a large irregular mass, and holding down the wisdom 
tooth. It was easily removed. 

Ml'. Annandale has reported {Edinburgh Medical Journal, 
Jan. 1873) a sixth case occurring in the lower jaw of a young 
woman, aged seventeen, who had never had any molar teeth 
on the left side. A nodulated mass, which somewhat re- 
sembled a piece of necrosed bone, projected above the gum, 
and was firmly fixed. Mr. Annandale dislodged the growth 
and removed it through the mouth. It measured 1^ by \\ 
inches, and weighed 300 grains, and on section showed " that 
a cap of enamel, varying in thickness, was arranged over a 
portion of the irregular surface of the mass. Beneath this, 
well-formed dentine, forming a considerable thickness, w^as 
met with ; and still deeper in the substance of the mass, true 
bone, containing lacunae, canaliculi, and Haversian canals, 
was seen to be intermingled in a confused manner with 
portions of dentine, so as to form the substance called by 
histologists " osteo-dentine." 

The seventh case occurred in the practice of Dr. Good- 
willie, of IS^ew York, and is mentioned in Agnew's "Surgery/' 



author's case. 221 

vol. ii. It appears to have bsen removed witli the angle of 
the jaw. 

An eighth case has been recorded by myself in the Clinical 
Soeidi/'s Transactions, vol, xv. All these specimens were 
met with in young adults, and only the first, fifth, sixth, 
and eighth were extracted from the jaw by the surgeon, in 
Mr. Harrison's case the mass coming away spontaneously, 
and in Mr. Tomes' and M, Forget's cases a considerable 
portion of the lower jaw being removed by such experienced 
surgeons as Sir William Fergusson and M. Maisonneuve. 
In my own case I must confess that I did not appreciate at 
first the nature of the tumour, and recommended removal of 
a portion of the jaw, and that it was only during a subse- 
quent operation undertaken for supposed necrosis that the 
true nature of the case became apparent. 

Miss C.aged eighteen, the daughter of a dental surgeon, was 
brought to me in July, 1881, with a considerable swelling of 
the right side of the lower jaw, some of which was evidently 
inflammatory, and partly the result of previous treatment ; 
but there was, I thought, sufficient evidence of expansion of 
the jaw to warrant the opinion that a tumour was present, 
and I therefore recommended the removal of a portion of tlie 
jaw. Suppuration was tlieu present, and with the finger a 
rough surface of apparently exposed bone could be felt, but 
this I regarded as the result of inflammatory action excited 
by the injudicious irritation of a periosteal growth, since 
partial necrosis of a jaw involved by cartilaginous or malig- 
nant growths, which have been irritated by exploratory 
measures, is in my experience by no means uncommon. The 
patient had the advantage of the opinion of Sir James Paget, 
who was not perfectly satisfied as to the existence of a tumour, 
and expressed a hope that the case might prove to be one of 
necrosis. Under these circumstances the operation was 
postponed. 

On my return to town in September I found the patient 
improved in health and the swelling diminished by the sub- 
sidence of the inflammation, but a considerable enlargement 
of the lower jaw still present, with a sinus opening externally. 



222 



ODONTOMATA. 



From the mouth a white mass was visible, which, appeariug 
among granulations, looked like necrosis, and I agreed that 
an attempt should be made to remove this, although I could 
not think it accounted for the expansion of the jaw. On 
September 8, with the assistance of Dr. Snow, the patient 
was put under chloroform, and I proceeded to examine the 
mouth with my finger. I soon found that the white mass 
was not bone but tooth, and yet was unable to make out 
its outline. I was unable to make any impression M'ith a 
chisel or gouge, but at last Avith an elevator succeeded in 
lifting out of its bed a mass of dental structures, forming the 
odontoma shown in fios. 103 and 104. 



Fjg. 103. 



Fu;. 104. 




The mass measured IJ inches antero-posteriorly, 1 inch 
transversely, and IJ inches from above downwards. It 
weighed 315 grains = 5 v. gr. xv. 

A section of the odontoma has been made, and it has been 
submitted to Mv. Charles Tomes, wlio has kindly furnished 
the following report : — 

" The whole surface of the odontoma is nodulated and 
roughened by stalactitic excrescences, and there is at no 
point any form recalling the character of a tooth crown. 

" The surface of a section presents a complicated marbled 
pattern, due to the admixture of several dental tissues, and 
it bears a general reseml)lance to that form of dentine known 
as ' plici-dentine,' or ' labyrintho-dentine.' On the wJiole 
the mass is of tolerably uniform structure throughout, though 
there is an area of somewhat simpler structure in its upper 



ODONTOMATA. 223 

aucl central portion, from which folds of dentine appear to 
radiate. So far as it goes, this would seem to point to the 
whole mass being the product of a single tooth germ rather 
tlian of several fused together, a matter which was left in 
some doubt by the absence of an accurate history of the 
case. 

" The excrescences of the surface, as well as the greater 
part of the interior, are made up of folds of dentine, in which 
dentinal tubes are very abundant, and which surround 
flattened remnants of pulp chambers ; between and intimately 
blended with this comparatively well-formed dentine, is a 
more coarsely calcified material, containing numerous lacunse, 
and ])ermeated by vascular channels — in fact, osteo-dentine. 

"Enamel is present upon some of the nodules of the 
surface, but it does not by any means form a complete in- 
vestment ; where present it dips in folds, following the 
convolutions of the dentine, and it is to be met with in the 
very centre of the mass, though not very abundantly. It is 
nowhere well formed, being brownish and opaque. 

" This odontoma is the product of the formative dentine 
pulp of a tooth (or teeth) which has, in place of remaining 
simple, budded out innumerable processes on all sides, and 
finally has calcified ; its enamel pulp has in parts followed 
the complexities of its surface, and in parts failed to do so, 
or, at all events, has failed to perpetuate itself by calcifica- 
tion." 

Another form of tumour connected with a tooth con- 
sists in an outgrowth from a more or less perfect tooth, de- 
pending upon some modification of the dentinal pulp, after the 
formation of the dentinal cap. These growths belong to the 
Odontomes coronaires of Broca, and have been described as 
ivarti/ tcdh by Salter. The smaller warty teeth have no 
special surgical interest, but occasionally the outgrowth takes 
place after the completion of the crown of the tooth, and 
is large enough to form a tumour recpiiring surgical inter- 
ference. The rare examples of tliis form the class Odontomes 
radiculaires of Broca. A remarkable specimen of the kind, 
in the Museum of the Collesie of Suroeons of England 



224 



ODONTOMATA. 



(2168), has been especially investigated by ]\Ir. Salter {Guy's 
Hoqntal Reports, 1869), who believes that the outgrowtli 
is due to " hypertrophy and dilatation of a fang, and 
not, as was formerly supposed, to hypertrophy of the 
cementum. Fig 105, from Mr. Salter's paper, illustrates the 

Fig. 105. 




structure of the tumour, and fig. 106 shows the relation of the 
growth to the tooth. The outer layer is composed of 
Fifi. 106. Fig. 107. 





cementum, or tooth-bone, and within this is a layer of true 
dentine, which is wanting below ; and within this again is the 



ODONTOMATA. 225 

" nucleus" of calcified tooth-pulp. This last is " composed of 
a confused mass of bone- structure and dentine- structure, 
arranged around and separating an elaborate vascular net- 
work of the same character as that of the dentinal pulp." 

Almost synchronously with, but independently of, Salter, 
Professors Heider and Wedl {Atlas zur Pathologie der 
Zciline) described a tooth-tumour resembling in many respects 
that at the College of Surgeons. 

A still larger specimen in connection with the side of a 
molar tooth is given in fig. 107, from a case recorded by Dr. 
Forget (oj;. cit). It occurred in the practice of M. Maison- 
neuve, and in the person of a man aged forty. The tumour 
occupied the left side of the lower jaw, causing both its 
sm-faces to project, but especially the outer. At the smaller 
end of the tumour was a decayed molar tooth, and upon 
extracting this the tumour came away with it. The growth, 
which was larger than a pigeon's egg, was attached to the 
tooth by a kind of pedicle, a section showing a line of 
separation between it and the root of the tooth. Under the 
microscope the specimen was seen to contain no dentine, 
but to consist exclusively of osseous tissue. 

In April, 1863, Mr. Tomes exhibited to the Odontological 
Society an extraordinary specimen of so-called exostosis, 
shown in the illustration (fig. 108), which I have been per- 

FiG. 108. 




mitted to Ijorrow from the Transactions of tlie Odontological 
Society (vol. iii.). The molar tooth, to which it is attached, 
was removed by Mr. Hare, of Limerick, from the upper jaw 
of a man aged forty-one. who had long suffered pain in the 
jaw, from which a fistulous passage led through the cheek. 
The growth is more or less hollowed out, and on this account 

Q 



226 ODONTOMATA. 

it lias been suggested that it may possibly be an instance of 
calcified dental cyst. The specimen has, however, recently 
undergone careful microscopic examination by Mr. Charles 
Tomes, who found that it closely resembled Forget's specimen 
already described (fig. 107), of which a microscopic section 
is given by Broca. Mr. C. Tomes brought the preparation 
before the Odontological Society in January, 1872, and has 
shown that the outgrowth is not connected with the fangs 
of the tooth, but had sprung from the dentinal pulp. This 
latter he believes to have undergone partial destruction 
before becoming calcified, and hence the cavity formed in 
the tumour. {Transactions of the Odontological Society of 
Great Britain, Jan. 1872.) AVliatever its nature, it must, 
from its size, have either invaded or obliterated the antrum. 
It will be obvious, fi'om a consideration of the preceding 
cases, that every effort should be made to extract an odontoma 
from the jaw without removing any portion of the bone itself. 
In the case recorded by Mr. Harrison, the tumour was 
enucleated spontaneously, in four cases it was removed 
without difficulty, and in two other cases its removal was 
readily effected after the containing portion of jaw had been 
excised. Where the growth is presumably connected with 
a tooth, the rule of removing all neighbouring teeth which 
may possibly be connected with it, should be invariably 
followed before any more serious operation is undertaken. 



227 



CHAPTER XV. 

DISEASES OF THE GUMS, EPULIS. 

Hypertrophy of the Gums is a by no means common affec- 
tion. Mr. Salter has recorded (" System of Surgery," ii.) a re- 
markable case which occurred in St. George's Hospital in 
1859, in a girl of eight years, in whom there was precocious 
development of the teeth, accompanied by hypertrophy of the 
gums. A large, pink, smooth mass projected from the mouthy 
slightly corrugated or indistinctly lobed, which consisted 
of an expansion of the alveolus, immense hypertrophy of the 
fibrous gum, and an exuberant growth of the papillte of the 
mucous membrane. Dr. Gross has narrated a very similar 
case in his "System of Surgery" (1862). In April, 1867, I 
liad the opportunity of seeing a case of the kind, under the 
care of Mr. Erichsen, in University College Hospital. A child 
of two and a half years had hypertrophy of the gums, which 
were prolonged in front of and behind the teeth so as almost 
to conceal them. The disease affected only the incisive por- 
tions of both jaws, and it was remarkable that the temporary 
teeth had undergone hypertrophy also, being considerably 
larger than normal. The affection first showed itself at the 
age of seven months, when the teeth began to appear, the 
gums increasing in size and bleeding on the least touch. Mr. 
Erichsen removed the exuberant growth, extracting some of 
the teeth, and freely cauterized the cut surfaces. In Mr. 
Salter's case it was necessary to clip away portions of the 
alveolus as well. The excised portions in Mr. Erichsen's 
case were examined by the late Mr. A. Bruce, who gave 
the following report upon them : — " On section the mass was 
found to consist of a firm fibrous stroma, containing much 

Q 2 



228 DISEASES OF THE GUMS. 

glandular tissue in its interstices, and covered on its surface 
by very large and vascular papillai. The epithelial layer was 
of unusual thickness, but no abnormal epithelial structures 
were found in the growth, which was an example of true 
hypertropliy." These characters agree closely with those 
observed by Mr. Salter, and it may be remarked that though 
in his case the temporary teeth do not appear to have been 
hypertrophied, yet that the permanent teeth exposed in the 
alveoli by the operation were excessively large, especially the 
superior central incisors. I am able now to supplement my 
report of Mr. Erichsen^s patient operated upon in 1867 when 
2^ years old, from the Medico-Cliirurgiccd Transactions, vol. Ivi,, 
to which the late Dr. John Murray, of the Middlesex Hospital, 
contributed a paper " On three Peculiar Cases of MolJuscum 
Fibrosum in Children of one Family." The eldest of these 
was Mr. Erichsen's patient, now seven years of age, and she 
presented peculiarities of the skin, subcutaneous connective 
tissue, periosteum and ends of the fingers and toes. Dr. 
Murray's description of the oral cavity is as follows : — " The 
appearance of the gums is very remarkable. They are every- 
where greatly hypertrophied, and they almost completely 
bury the teeth. They form in parts numerous papillomatous 
or polypoid-looking growths, and in other situations present 
a peculiar fungating appearance, indeed this latter charac- 
teristic of the growth is at once observed. The teeth, 
although almost buried by the hypertrophied gum, are still 
in every case visible, and are, in some measure, serviceable 
for the purposes of mastication. The enlargement of the 
gums is most marked at their upper and free surface, where 
they are mostly flattened out and in parts hardened by the 
pressure of the opposing gum. They present the natural 
colour, and although they are in parts somewhat soft, 
vascular, and spongy-looking, they mostly feel firm and 
fibrous to the touch, the disease being distinctly limited to 
the gums." 

The patient's brother, aged four, in whom the growth was 
first observed when he was three months old, and her sister, 
aged two, have a similar condition of the gums. 



HYPERTROPHY OF GUMS. 



229 



It is remarkable that in all cases recorded there was a 
defective mental condition, and the hypertrophy of the gums 
had been noticed quite early in life, and seemed to have been 
general, affecting equally both jaws, and the whole extent of 
the alveolar arch. A case of hypertrophy of the gums, 
in a woman aged twenty-seven, was published by Dr. 
Waterman, of Boston {Boston Medical and Surgical Journal, 
April 8, 1869) ; but the most remarkable instance of the 
disease on record, also occurring in the adult, is given in the 
Austrcdian Medical Journal, for August, 1871, by Mr. Mac- 
Gillivray, surgeon to the Bendigo Hospital, to whom I am 
indebted for photographs of the patient (fig. 109). The 

Fig. 109. 




patient, a woman aged twenty-nine, seemed to have suffered 
from the affection in both jaws at or soon after birth. At 
the age of ten portions of the gum were cut away, and 
several teeth extracted, and she had herself in later life cut 
off portions of the projecting gum with a razor. All these 
operations gave rise to severe hccmorrhage. The enormous 
growth shown in the drawing seemed to have originated 
mainly from the palatal portion of the gums, the labial 
surface being comparatively sound. Mr. MacGillivray 
removed the hypertrophied gums and alveoli with perfect 
success. 

In December, 1878, I brought before the Odontological 



230 DISEASES OF THE GUMS. 

Society of Great Britain two cases of hypertrophy of tlie 
gums which I had treated successfully by operation, one in 
a child, and the other in an adult. 

The first case was that of Amy B., ret. four years and a half, 
who was admitted into University College Hospital, May 6, 
1878. She is one of five children ; the otlier four are 
healthy. Two years ago the swelling of the gums began by 
the side of the temporary molars, which were just coming 
through, and from them the swelling has spread right round 
the jaw. At this time she had fits about once a M-eek ; the 
fits have continued up to the present time, but with longer 
intervals. They appear to be epileptic. 

The patient is a very tractable child ; her general health 
appears to be good. The gums are enormously hypertro- 
phied, the teeth being entirely covered, with the exception 
of the tips of the crowns, wliich appear depressed in the 
gums. The lower gums are shown in fig. 110, and the upper 
in fig. Ill, taken from casts. The preparation is in Univer- 

Fk;. 110. Fig. 111. 




sity College Museum (1010 A). The hypertrophy of the 
gums is so great that the cheeks are bulged out on each side, 
and the cavity of the mouth is almost filled with them. 
The teeth are irregular and slightly carious. The child is 
always biting and putting cold things in her mouth. She can 
bite nothing hard, and has been fed entirely on liquid or 
pulpy food. Her breath is very offensive. 

On May 9, under chloroform, I removed the hyper- 
trophied gums and the alveolar margin of the lower jaw in 
two pieces. On one side the first permanent molar came 
away ; on the otlier side it was left, not being quite erupted. 



HYPERTROPHY OF GUMS. 231 

Haemorrhage, which was free, was stopped with the actual 
cautery. 

On May 23, under chloroform, I detached the hyper- 
trophied gums and alveolar border of the upper jaw in one 
semi-circular piece. Eoots of the permanent teeth left. 

On June 3 the patient was discharged well. 

A microscopic examination by Mr. Charles Tomes, showed 
that the structure of the growth closely resembled that of 
the small polypi which are sometimes found occupying the 
cavity of carious teeth : it was a true hypertrophy of the 
gum., and chiefly of the fibrous portion. It sprang from the 
periosteum round the neck of the teeth, just within the 
margin of the alveoli. From this point a dense stroma of 
interlacing fibres, covered by a thin mucous and epithelial 
layer, grew up round the tooth, the growths from opposite 
sides meeting over it and coalescing, so as almost to cover it. 
The attachment within the socket was im];)ortant, for this 
explained how it was that a successful result could not be 
obtained without removing part of the alveolus. Unless this 
was done, the base of the growth was left behind, and recur- 
rence soon took place. 

The second patient, Mv. L., let twenty-six, came under my 
care in June, 1877, with hypertrophy of the gum and alveoli 

Fic. 112. 




of the right side of the lower jaw, extending from the right 
wisdom-tooth to the left canine. The aiTection had been 
noticed from early childhood, and gave no pain. The condi- 
tion of the gum is seen in fit^. 112. 



232 DISEASES OF THE GUMS. 

On June 19, the patient being nnder chloroform, I 
removed the affected alveohis with Liston's powerful cross- 
cutting forceps. The widom-tooth was left, but the other 
teeth were necessarily sacrificed up to the left canine. The 
hsemorrhage was free, but was controlled with the actual 
cautery freely applied, and the patient made a good recovery 
in a fortnight. Mr. Ibbetson subsequently fitted some 
artificial teeth ; the patient is now in much gTeater comfort 
than before. 

The growth is fibrous in structure, and is an example 
of pure hypertrophy. The preparation is in University 
College Museum (1010). 

In conclusion, I would say that nothing less than com- 
plete removal of the affected alveolus seems to offer any 
hope of alleviating these cases. Mr. Erichsen in 1867 
thoroughly pared off the exuberant growth of the girl 
Ellen S., but in 1872 there was complete reproduction of 
the disease. In the child operated upon by me, the condition 
of the gums was such as mechanically to interfere with 
taking food, so that there was no hesitation in sacrificing 
the temporary teeth ; and it may be hoped that many of 
the permanent teeth escaped injury, and may be erupted 
in due course. 

Hypertrophy of the gums from the irritation of badly 
fitting artificial teeth is occasionally met with in elderly 
patients, and in one case, a lady whom I saw in consulta- 
tion with Mr. Eichardson, and in whom the disease had 
existed for ten years, I found it necessary to remove with 
Paquelin's thermo-cautery a considerable amount of tissue, 
before it became possible to have fresh artificial teeth fitted. 

Polypus of the gum is the name given to a simple hyper- 
trophy of the portion of gum between two teeth, which is 
ordinarily dependent upon the irritation caused by those 
organs, and may be sessile or pedunculated. It is often 
connected with accumulations of tartar around the necks 
of the teetli, and with a generally unhealthy condition of 
the mouth, and if cut away with scissors and freely 
cauterized with the nitrate of silver, or better, Paquelin's 



VASCULAR GROWTHS OF THE GUMS. 233 

thermo-caiiteiy, does not recur. In one case of large polypus 
over a central incisor which had been pivoted, and was 
doubtless a source of irritation, I thought it safer to 
remove a small piece of alveolus with the bone-forceps 
after extraction of the tooth, but this is exceptional. Mr. 
Salter describes a condylomatous form of disease of the 
gum which is of a syphilitic character. 

Vasc^dar growths are occasionally met with in connection 
with the gum, and especially in the region of the incisor 
teeth. These bleed freely when rubbed with the tooth- 
brush, and may, if neglected, grow to some size, resembling a 
nsevus in their colour and appearance. Stanley, in his work 
" On Diseases of the Bones," has narrated and drawn a case 
in which there was a vascular growth in the region usually 
occupied by these growths, but in that instance the tumour 
sprang from the interior of the jaw and necessitated re- 
moval of a portion of it. 

Mr. Tomes has successfully treated the three or four 
examples of the disease he has met with, by the frequent 
application of powdered tannin. Mr. Salter narrates in the 
" System of Surgery," a case in which htemorrhage arose from 
a growth of the size of a marble, which he successfully treated 
by excision and the application of the actual cautery, after 
having failed to effect a cure with the ligature. I have also 
met with an example of pedunculated tumour of the gum in 
a woman aged twenty-five ; it bled when touched, and the 
pedicle apparently passed through the alveolus. I removed it 
in June, 1869, by tearing through the pedicle with the finger 
nail, and applied the actual cautery to the spot from which 
it grew, which bled freely. I have twice met with a very 
vascular and hypertrophied condition of the gums in patients 
the subjects of " port- wine stain" of the face. In a young 
married woman of twenty- four, the gums of both jaws on 
one side were affected, and became more developed and 
vascular during each pregnancy, so that she lost a good deal 
of blood. I twice removed the growth, arresting the 
haemorrhage, which was not severe, with the actual cautery. 
In the- other case, of a young lady of seventeen, the lip 



234 



DISEASES OF THE GUMS. 



and upper gum were affected, and I was able to bring about 
a cure by drilling with a sliarp-pointed cautery. 

Papilloma of the Gum. — Mr. Salter has, in the Guy's 
Hospital JRcjyorts (1866), called attention to a rare form of 
disease in connection with the jaws, which appears to consist 
essentially in a hypertrophy of the papillce of the mucous 
membrane. The disease was first noticed by Sir William 
Fergusson, in the lower jaw of an old man of eighty, and 
''looked like vegetable matter, or greatly elongated papilhe," 
as described in some clinical observations on the case by that 
surgeon in the Lancet, September 6, 1862. It was removed 
by Sir William Fergusson, and is described by Mr. Salter as 
" a curious white mass, consisting of coarse detached fibres, 
pointed and free at one extremity, and attached at the other ; 
in fact it was a mass of papilla?, many of them nearly an inch 
long, and sunilar in shape to the ' filiform' papilhe of the tongue; 
their surface was shreddy and broken ; among these elongated 
processes were a few rounded eminences like ' fungiform' 
papillae, and these had a smooth unbroken surface." The 
accompanying drawing (lig. 113) for which, as well as for 

Fig. 113. 




those that follow, I am indebted to Mr. Salter, represents a 
portion of the tumour of the natural size. Microscopically 
the mass consisted almost entirely of epithelium. 

Mr. Salter met with a second case in the practice of Mr. 
Cock, at Guy's Hospital. It consisted in a growth of the 
size of a split chestnut attached to the hard palate of the 
right side, and extended from the edge to near the median 
line, as seen in fig. 114, and had been growing about eight 
months. Mr. Cock extirp.ated the growth, which consisted 
of a hard mass of fibrous tissue, surmounted by ^^apillte, 



EPULIS. 



235 



maiuly composed of dense coherent epithelium ; and met 
with considerable difficulty in arresting the free h£emorrhage 
which ensued. Fig. 115 represents a section of the growth 



Fin. 11 4. 




of the natural size. The growth recurred after some time, 
and took a malignant form, which proved fatal. 




Epulis. — The growths connected more or less closely 
with the gums vary somewhat in their nature, but are 



Fig. 116. 




conveniently classed together under the term epulis. The 
ordinary form of the disease is a firm fibrous tumour, of 



236 EPULIS. 

slow gTOWth, ill which, in many instances, some fibro- 
plastic cells are intermingled. Hence modern patholo- 
gists regard epulides as examples of ossifying sarcomata 
(Cornil and Eanvier). The accompanying drawing (fig. 116), 
for which I am indebted to Mr. Jonathan Hutchinson, gives a 
good idea of the naked-eye appearance presented by a section 
of an epulis of large size. This form of the disease is 
closely connected with the fibrous gum, and also with the 
periosteum of the alveolus, and very generally small spicula 
of bone are prolonged into it from the maxilla ; the mucous 
membrane of the gmn is stretched over the growth. Occa- 
sionally a development of true bone takes place in distant 
parts of the growth, as in the specimen drawn above ; so 
also in a large epulis which I removed from the upper jaw 
of a young woman, and which accompanied this essay 
(College of Surgeons' IMuseum, 2191), a nodule of bone of 
considerable size is developed near the surface of the growth 
and quite unconnected with the alveolus. Mr. C?esar 
Hawkins mentions {Medical Gazette, 1846) a similar occur- 
rence in a case where the epulis was pedunculated. 

The myeloid, or softer and more vascular form of epulis, is 
composed of a small quantity of fibrous tissue, holding in its 
meshes the true polynucleated myeloid cells, or " myelo- 
plaxies," The drawing from which fig. 117 was taken (also 

Fic. 117. 




given me by Mr. Hutchinson), showed the vascular appearance 
of such a tumour on section, the one in question having formed 
a large overhanging mass upon the lower jaw, which was 
excised by Mr. Curling in 1864. 

In fig. 118 is seen a section of a well marked myeloid epulis, 
removed by Mr. Wilkes, of Salisbury (College of Surgeons' 



MYELOID EPULIS. 237 

Museum, 2192). The tumour consists of a semi-globular 
hrm elastic mass attached by its base to the margin of the 
alveolus, from within which it springs. Its surface is smooth 
and uniform, and of a dark grey colour, mottled with purplish 

Fig. 118. 




spots. On section it can be traced into the bone, the cut 
surface being for the most part of a greyish yellow, with 
patches of pink and purple. The microscopical examination 
shows interspersed among the fine fibrous tissue some large 
irregular disc-like cells, containing numerous bead-like nuclei, 
and the growth may therefore be considered similar to that 
described by Otto Weber, as " giant-celled sarcoma." 

This form of epulis is more commonly connected with the 
interior of the alveolus than the fibrous variety ; and this 
fact may possibly account for its being more closely allied 
to the endosteal than the periosteal structures. In fact, 
many of the so-called myeloid epulides are really only out- 
growths from myeloid tumours of the interior of the jaw, and 
hence their great tendency to recur if insufficiently removed. 
It is this form which, when irritated and ulcerated, presents 
an appearance somewhat resembling malignant disease. Ir- 
regular nodules of bone may be scattered through the myeloid 
as through the fibrous variety, and the occasional occurrence of 
a cyst in connection with an epulis must not be overlooked. I 
have recently had a case of the kind under my care, in which 
the i^resence of a cyst by the side of a fibrous epulis gave a 
formidable appearance to a simple disease. 

A form of epulis possessing some of the characters of 
epithelioma is occasionally met with. A sjDecimen which 
was sent to me in a perfectly fresh state by Mr. Hutchinson, 
who had removed it from the lower jaw of a lady aged fifty- 



238 EPULIS. 

five, where it had been growing a year, was examined Ly 
the late ]\Ir. Bruce with the following report : — " The surface 
of the tumour is covered with healthy mucous membrane. 
The interior of the tumour is whiter, firmer, and more com- 
pact than the surface ; but there is no line of demarcation 
between the tumour and its mucous covering. The structure 
of the growth is distinctly glandular, very much resem.bling 
some forms of compact adenoid tumour of the breast. At 
the point of attachment of the tumour to the parts beneath, 
a remarkable transformation of the glandular into the epithe- 
liomatous structure is seen. In one part of the section may 
be seen the cut ends of gland tubules, whilst in their im- 
mediate neighbourhood are most distinct nests of true epithe- 
lioma, consisting evidently of concentrically arranged cells 
compressed from the centre outwards." 

Mr. Eve has also placed in tlie Museum of the College of 
Surgeons an epulis (2193 A) which microscopically had the 
character of an epithelioma, but contained no " cell-nests." 

Epulis appears to be generally connected with the presence 
of teeth, and in some cases to depend upon the irritation 
caused by them ; but I have once seen a small fibrous epulis 
in a newly-born child. The simplest form is often found gi-ow- 
ing between two perfectly sound teeth, which become widely 
separated, as seen in the illustration (fig. 119), taken from a 

Fig. 110. 




patient of Dr. Langston, in whom I was obliged to sacrifice 
the central incisors in order to remove the growth ; in some 
instances the pedicle attaching the growth may be so slender 
as to be broken by the tongue of the patient or the finger of 
the surgeon, of which Sir William Fergusson gives examples. 
The teeth may be unsound and broken, and in these cases 



STATISTICS OF EPULIS. 239 

Tahular Statement of Tivcnty-cifjlit Cases of Epulis. 



No. 


Sex 


Age 


Duration. 


Position. 


Result. 


■ 
Remarks. 


1 


F. 


35 




Upper. 


Recovered. 




2 


M. 


39 


15 months. 




Recovered. 




3 


F. 


60 


7 months. 


Upper. 


Recovered. 




4 


F. 


50 


3 months. 


Upper. 


Died. 


Rigors followed the opera- 
tion, and death from py- 
emia on the 15th day. 


5 


M. 


16 


3 years. 


Lower. 


Recovered. 




6 


F. 


60 


20 years. 


Upper. 


Recovered. 


Very large indeed. It had 
returned after removal 8 
years before. 


7 


F. 


26 


9 months. 


IjQwer. 


Recovered. 


Large, ragged, andfungat- 
ing. It was fibi'O-cartila- 
ginous. 


8 


M. 


36 




Upper. 


Recovered. 


It was thought after re- 
moval to be of cancerous 
nature. 


9 


M. 


27 


7 years. 


Upper. 


Recovered. 


The tumour was thought 
to be cancerous after re- 
moval. 


10 


F. 


28 


6 years. 


Lower. 


Recovered. 


The tumour consisted of 
hardish bone, and had en- 
capsuled completely the 
stumps of two teeth. 


11 


F. 


11 




Lower. 


Recovered. 




12 


F. 


36 


18 months. 


Lower. 


Recovered. 


Caused by a decayed tooth. 


13 


M. 


24 






Recovered. 




14 


F. 


30 




Upper. 


Recovered. 




15 


F. 


23 


14 months. 


Lower. 


Recovered. 


Two bicuspid teeth were 
buried in it. It was of 
myeloid structure. 


16 


F. 


22 


2 years. 




Recovered. 


It involved two teeth. 


17 


M. 


16 


1 year. 


l/ower. 


Recovered. 


It involved the last bicus- 
pid and first molar. 


18 


F. 


31 




Lower. 


Recovered. 


The tumour was soft and 
fungoid. 


19 


F. 


30 




Lower. 


Recovered. 




20 


M. 


9 






Recovered. 




21 


F. 


22 




Lower. 


Recovered." 




22 


M. 


40 






Recovered. 




23 


M. 


40 






Recovered. 


It was ulcerated, and con- 
sidered to be malignant. 


24 


M. 


10 




Lower, 


Recovered. 


As large as a walnut. 


25 


M. 


51 




Upper. 


Recovered. 




26 


F. 


47 


5 months. 


Upper. 


Recovered. 




27 


F. 


24 




Lower. 


Recovered. 


The bleeding which fol- 
lowed required the actual 
cautery for its arrest. 


28 


F. 


73 


... 




Recovered. 


The tumour was peduncu- 
lated, and was removed 
by ligature. 



240 EPULIS. 

the growth often completely envelops the stumps and hides 
them fi'om view, or in the progress of the growth a fang of 
a tooth may be pushed forward, and be eventually found 
imbedded in its centre, as narrated by Mr. Tomes. 

The accompanying statistics respecting epulis (p. 239), 
founded upon twenty-eight cases observed in the London 
Hospitals, are taken from the Medical Tiincs and Gazette, 
Sept. 3, 1859. 

" Of these twenty-eight cases in which tumours growing 
from the gum were of the character usually designated as 
' Epulis,' we may make the following summary : — In but 
one instance did the operation cause the death of the patient, 
wliilst in all the others the parts implicated are stated to 
have healed soundly. It would appear that the female sex 
is mure liable to this disease than males, in the proportion of 
five to three, the numbers in the list being seventeen females 
and eleven males. This may perhaps be explained by reference 
to the fact, that stumps of decayed teeth are by far the most 
frequent exciting causes of these growths. Now, women are, 
for several reasons, more likely to retain useless stumps of 
teeth than men. Tliey are far more patient as regards severe, 
unavoidable pain, such as that of toothache, and at the same 
time much more afraid of surgical pain, as that of tooth ex- 
traction ; besides, it must be remembered, that the conditions 
either of pregnancy or lactation prevent many women from 
having their decayed teeth taken out at the time when they 
ache. 

" As it regards age, we find that the youngest patient was 
a boy of 9, and the next to him a girl of 1], wliilst the 
oldest was a woman of 73, and the next to her another 
woman of 60. Five w^ere under the age of 20 ; eight between 
those of 20 and 30 ; seven between 30 and 40 ; three be- 
tween 40 and 50 ; two between 50 and 60 ; and three above 
60. The average age of the whole number is 33." 

The two jaws appear to be equally liable to the disease, 
but its position and extent are subject to great variation. In 
the simplest form it may be connected with only the outer 
plate of the alveolus, or may be attached at a slight depth 



EPULIS. 241 

within tlie socket of a tootli. In other instances it is at- 
tached solely to the posterior plate of the alveolus, and pro- 
trudes the teeth or appears Ijehind them ; in the more severe 
cases of myeloid disease it involves the whole thickness of 
the jaw, and either envelops or carries the teeth before it. 
Of this a case of Dr. Fleming's {Duhlin Qnartcrhj Journal, 
Feb. 1866), gives a good example at an unusually early age, 
the boy being between five and six, and the disease occurring 
between the first and second temporary molar teeth of the 
lower jaw, both of which were displaced and imbedded in 
the morbid growth. 

Wlien the tumour attains a moderate size, if it be on the 
upper surface of the alveolus it is apt to be pressed upon by 
the teeth of the opposite jaw, and this not only gives rise to 
pain and inconvenience, but causes also indentations and 
possibly ulcerations on its surface. Fig. 120 is reduced from 
a cast of the upper jaw of a young woman, a patient of Mr. 

Fig. 120. 




Warn, of the Higbgate Road, from whom I removed a large 
epulis containing bone, which has been already referred to. 
The patient was twenty- seven years of age, and the growth 
had existed two years, and it will be seen that the surface is 
grooved and indented by the teeth of the lower jaw. In this 
case the fangs of the first and second molar teeth were found 
in the alveolus beneath the epulis. 

A fibrous epulis, if allowed to grow to a large size, will 
produce external deformity of the face, and although attached 
to the upper jaw may hang down so as to simulate disease 

R 



242 



EPULIS. 



of the lower jaw. This was well seen in a woman, aged 
twenty-seven, who had an epulis of the upper jaw of seven 
years' growth, which hung down to the level of the angle of 
the jaw, and who was under the care of Mr. Erichsen, by 
whom the tumour was removed in 1861, with perfect success. 
Perhaps the most remarkable case of epuloid growth on 
record, however, is Mr. Listen's well-known patient, Mary 
Griffiths, from whom, in October, 1836, he removed the 
growth shown in the accompanying drawing (fig. 121). 



Fig. 121. 




The case is reported at length in the Lancet of November 5, 
1836, and is also referred to in Mr. Liston's " Practical 
Surgery," from which both the illustrations are taken. 
The following summary of it is from a note to Mr. Liston's 
paper on Tumours of the Jaw in the Mcdico-Chirunjical 
Transactions, vol. xx. 

" The patient had laboured under the disease for eight 
years, and had been subjected to a partial removal of the 
growth when of inconsiderable size. The tumour was of the 



MR. LISTONS CASE. 



243 



same nature as those of the third and fourth cases related 
in the paper (i.e., fibroid), as regards its disposition, form, 
and intimate structure. It differed somewhat, however, in 
outward appearance, in consequence of its exposed situation. 
The growth sprang originally from the gums and sockets of 
the incisors and canine tooth of the left side ; at an early- 
period it protruded from the mouth, unconfined and uninflu- 
enced by the pressure of the lips or cheek. It had assumed 
a most formidable size and appearance, concealed the palate 
and pharynx, and gave rise to great inconvenience and con- 
tinued suffering. The surface had been broken by ulcera- 
tion, but upon a close inspection of the projecting pnrt and 
of that covered by the cheek, it was found to possess a firm 
consistence, and to present the same peculiar botryoidal 
arrangement of its parts as the others of a simple and 
benign nature. The operation proved perfectly successful." 

Fig. 122. 




Fig. 122 shows the after-condition of the patient, the scars 
in the upper lip being the result of the previous unsuc- 

r2 



244 EPULIS. 

cessful attempt to remove the disease. The preparation is 
in the Museum of the College of Surgeons (2193). 

A case, very similar in many respects to the preceding one, 
was successfully operated upon in 1869 Ly Professor Kinlocli, 
of Charleston. The patient was a negress aged twenty-five, 
and presented much the appearance shown in fig. 121, the 
mouth being enormously distended by a protruding growth, 
which appeared to have originated in the alveolus, but to 
have involved the superior maxilla. Dr. Ivinloch removed 
the mass, which weighed nearly two pounds, and the 
patient made a good recovery. 

Treatment of Eindis. — No treatment less radical than 
removal of the growth is of the slightest advantage. In the 
case of a small epulis growing between or close to the in- 
cisor teeth, after removal with the knife, an attempt may be 
made to check the reproduction of the disease by the appli- 
cation of nitrate of silver, or a fine cautery, but usually with- 
out success. An epulis attached to the outer surface of the 
alveolus only, may be broken away with the nail, and the 
surface be thoroughly cauterized, but, as has been already 
said, the growth is connected with the periosteum, and will 
often be reproduced from it. It is essential then to remove 
the peiiosteum, and this may be done with a chisel or gouge, 
by which a small scale of the alveolus with its covering can 
be cut away. Those who object to such a proceeding may 
produce the same result by the application of such a powerful 
caustic — either potassa fusa, nitric acid, or the hot iron — as 
shall destroy the surface of the bone and cause its exfoliation, 
but with some tediousness and inconvenience to the patient. 
In cases of large fibrous epulis, a tooth must be extracted on 
each side, and the whole thickness of the alveolus cut away 
with bone forceps, of which Liston's cross -cutting forceps, 
shown in figs. 123 and 124, are very serviceable ; the straight 
ones for the incisor, and the angular for the molar region. 
The same radical treatment will be advisable when the 
disease springs from the posterior plate, and in all these cases 
I make an invariable practice of applying the actual cautery 
to the surface of bone exjvised by the operation, which lias 



TREATMENT OF EPULIS. 245 

tlie lulvaiitagc of stopping luemorrliagG, and of causing the 
exfoliation of any diseased portions of bone which may 
have been left. In all operations of the kind, any roots of 
decayed teeth which may be discovered at the time of the 
operation should be extracted with the forceps or elevator, 
and the surface of the bone rendered as smooth as may be. 

Fig. 123. Fig. 124. 





When the epulis is connected with the lining membrane of 
the socket of a tooth, and dips down into the interior of the 
jaw, it is probably myeloid, and no superficial operation can 
effect a cure, since it is in this class of cases that repeated 
reproductions are met with. The neighbouring teeth, although 
sound, must generally be sacrificed, and the alveolus be 
thoroughly cleared out with the gonge, so that nothing but 
the shell of compact bone is left. The hemorrhage is usually 
free, and is best controlled by stuffing the cavity with lint. 
In 1875 I saw a young gentleman^ aged nineteen, with Mr. 
Braine, in whose lower jaw there was a small myeloid growth, 
which I freely removed. Eecurrence took place, however, 
and I 023erated a second time, clearing out the alveolus very 
thoroughly, but fortunately being able to preserve the teeth, 
and the patient is now quite well, eight years afterwards. 

When the epulis is very extensive, it may be conveniently 
removed with the alveolus to which it is attached, by making 



246 



EPULIS. 



a vertical incision with a small saw at each extremity of the 
disease, and then connecting the cuts l)y a liorizontal one 
with cross-cutting bone forceps. Under no circumstances, 
except when the growth is of a malignant character, can 
it be necessary, I believe, to cut through the whole thickness 
of the lower jaw, since it has been shown repeatedly that 
common epulis never involves the base of the bone, and the 
contour of the face depends so much upon its preservation, 
that it should not be interfered with. 

When the growth is of large size and situated at the side 
of the mouth, some dilliculty may be experienced in extir- 
pating it, but with properly made angular and semicircular 
bone-forceps (tigs. 125 and 126) this may generally be over- 



Fio. 125. 



Fig. 126. 





come. It may be necessary, however, to incise the face, 
and if so, the suggestion and practice of Sir William ¥ev- 
gusson (" Lectures on Progress of Surgery," p. 239) cannot 
be too strictly followed — viz., to restrict the incision to the 
middle line of the lip, which will ordinarily give abundance 
of room ; or, if not, to carry it into the nostril of the affected 
side, by the stretching of which so much additional room 
will be gained as to render any incision at the angle of the 
mouth perfectly unnecessary. When this limited incision 
is adhered to, the scar is so slight as to be imperceptible 



TREATMENT OF EPULIS. 247 

except upon the closest investigation. In instances of such 
enormous growths as in the case of Mary Anne Grifiiths, 
more extensive incisions, resembling those for excision of 
the jaw, would be required ; but such cases are now-a- 
days few and far between. Mr. Listen considered it neces- 
sary to remove the left and a portion of the right maxilla, 
but subsequent examination showed that these bones, though 
overlain by tlie disease, were not implicated in it except at 
their alveolar borders. 



248 



CHAPTEll XVI. 

TUMOUKS OF THE PALATE. 

Tmnours of the Hard Palate are for the most part closely 
allied to epulis, and may therefore be conveniently consi- 
dered here. A case of papilloma of the hard palate has 
been already described under tlie section of Papilloma 
of the Gum. In the ]\Iuseum of St. Bartholomew's Hospital 
is a preparation (XII. 1800), to which the following descrip- 
tion is appended — " An elongated oval tumour removed 
from the palate, to wliich it appears to have been attached 
by a broad base. It is composed of a firm, very closely- 
textured, obscurely-fibrous substance, with interspersed specks 
of bone, like the epulis which more commonly grows from 
the gums." 

Of this same character was a tumour of the hard palate 
removed by Mr. Keate, which Mr. Ca?sar Hawkins speaks 
of as essentially the same as epulis. Mr. Syme also narrates 
a case {British Medical Journal, April 19, 1862) occurring 
in a woman aged forty-six, which had been growing two 
years, was of a circular form, and " presented a convex sur- 
face extending from side to side and stretching from the 
anterior third of the palate to the posterior edge of its hard 
portion." The growth was soft at its centre, but hard at 
the base and evidently connected with the bone. Unfor- 
tunately no more detailed account of the structure of the 
growth is given in the lecture in question. 

Tumours of the palate of a softer consistence have been 
met with, however ; thus in St. Bartholomew's Museum 
(XII. 1799) are sections of a tumour removed from the 
palate, -to which it was attached by a base of much less 



TUMOUKS OF THE PALATE. 249 

extent than its circumference. Its surface is covered by 
thick, but apparently healthy, mucous membrane, and its 
interior is lobulated. 

Encysted tumours of the palate have also occurred ; thus 
Dr. Cabot showed to the Boston Society for Medical Im- 
provement a small round tumour, which he had removed 
from the roof of the mouth of a soldier. It had existed for 
eighteen months, and was situated on the posterior and left 
part of the hard palate, extending as far as, but not in- 
volving, the gum, Altliough the patient had suffered severe 
pain in the left side of the face and temple of a neuralgic 
character, yet he was not sure that it had its origin in the 
tumour. It was somewhat tender on pressure, but not pain- 
ful. The capsule which contained it being incised, it was 
easily slielled out. It was two-thirds of an inch in diameter, 
of a yellowish-white colour, and mostly smooth ; but in one 
part it had a warty appearance. 

A very similar case was under my care in 1876, of which 
tlie following are the details : — S. E — , aged forty-eight, was 
admitted on August 29, 1876. She stated that she had 
noticed a small lump on the hard palate since childhood, but 
it gave her ho inconvenience until about two years ago, when 
it began to enlarge, and from this time it steadily grew, and 
soon began to interfere with her articulation. Her health 
had, however, always been good. There was no history of 
tumour in the family. Tlie tumour filled up the hollow in 
the hard palate, being more attached to the left side, where 
the mucous membrane was continued directly over it, than 
on the right, where a probe could be passed between the 
tumour and the palate. It was about the size of a horse- 
chestnut, slightly lobed on the surface, elastic, but not lluc- 
tuating ; the mucous membrane over it was not adherent to 
it, and was normal in appearance. The tumour moved 
slightly over the bone. There were no enlarged lymphatic 
glands in the neck. The accompanying woodcut (tig. 127) 
was made from a plaster cast taken by a dentist. 

I removed the tumour by making an incision round the 
left side of the growUi, which then readily shelled out from 



250 



TUMOURS OF THE PALATE. 



a distinct capsule ; tlic capsule itself was afterwards removed 
with the fingers. ]>leeding was stopped by the actual 
cautery. The wound granulated, but left a part of the hard 
palate bare. A small portion of this was loose when the 

Fig. 127. 




patient left the hospital, and she stated that when she drank 
fluid came into the left nostril. 

The tumour was examined microscopically, and found to 
be a small round-celled sarcoma. 

A very similar tumour, removed by Sir W. Fergusson, 
is preserved in the Museum of the College of Surgeons 
(2284), being a round-celled sarcoma, half an inch in 
diameter, removed from a woman of thirty-live, in whom it 
had been growing four years. 

In the same Museum (2284 A) is a carcinomatous tumour, 
one inch in diameter, consisting of septa bounding alveoli, 
which contain collections of epithelial cells, removed by Mr. 
Bryant ; and in the Museum of King's College is a specimen 
of the kind, in which the greater part of the right side of the 
hard 2>alate is involved in a soft tumour, the surface of which 
is very ii regular ami biuken down, whilst the soft palate 



TUMOURS OF THE PALATE. 251 

appears to be free from disease. This was removed from 
the body after death, and no history is appended to it. 

A case of epithelial tumour of the palate in a young 
woman, aged sixteen, occurred in the London Hospital in 
1856, under the care of Mr. Curling, who successfully re- 
moved the growth with a large portion of the jaw ; the case 
will be found in the Lancet, July 26, 1856. 

Sir Andrew Clark's report of the tumour is as follows : — 
" The tumour is about the size and of the shape of a hen's 
egg. It is invested by a condensed layer of areolar tissue, 
and loosely connected with the periosteum of the adjacent 
bones. At one point — the posterior and inferior edge of 
the zygomatic surface of the superior maxillary bone — it 
had a limited but distinct osseous attachment. The tumour 
therefore might have been shelled out at all points but this. 
TJie tumour lies between the naso-palatine portion of the 
right maxilla and the mucous membrane. The mucous 
membrane over the tumour is hypertrophied, and exhibits 
an oval ulcer with thick, rounded, white margins, and a red- 
dish, smooth base. The naso-palatine part of the superior 
maxilla is elevated and thinned ; the periosteum is loosely 
attached to it, and at one point the bone is a little ' opened 
up' in texture. The tumour is soft, slightly elastic, and 
vascular. The cut surface is of a dead-white colour, dis- 
tinctly granular, like rough honey, crumbly-looking, and 
studded with red or pink blotched parts sunk below the 
general level. On further examination it appears to be 
permeated by a kind of glairy substance (colloid matter), 
which helps seemingly to give coherence to the tumour. To 
the naked eye the tumour resembles, in some respects, a 
cephaloid or myeloid mass. To the latter it bears the 
greatest resemblance in general character, seat, and struc- 
ture. The microscopic characters are those of epithelial 
cancer ; epithelial cells in all stages of development and of 
the most various forms, together with a few nest-cells and 
fat. The mucous membrane over the tumour, though not 
continuous with it, presents the same structural characters. 
Tliis decides the doubt between epithelioma and myeloma. 



252 TUMOURS OF THE PALATE. 

The tumour has Leeu wholly reinoved." {Lancet, July 26, 
1856.) 

But epitheliomatous ulceration of the hard palate is very 
often the result of extensive epithelioma of the antrum, the 
floor of which has become perforated, this being in some 
cases the first evidence of the disease. The consideration 
of these cases will be found in a subsequent chapter. 

Treatment. — When the disease is of the epuloid character 
the treatment should be the same as for that disease — viz., 
complete removal and destruction of the periosteum, from 
which the gi'owth springs. When the bone is implicated 
too deeply for the disease to be effectually removed with the 
gouge, the plan adopted by Mr. Syme in the case already 
referred to may be adopted. He removed the growth and 
the subjacent bone with a trephine large enough to embrace 
the whole tumour, leaving an aperture with healthy edges, 
which granulated and was much contracted when the patient 
was dismissed. When the disease is too extensive to be 
dealt with in this way, it will be necessary to remove a 
portion of the jaw, as in Mr. Curling's case. Under these 
circumstances the limited incision already insisted upon for 
cases of epulis should be had recourse to, and the jaw should 
be divided horizontally immediately above the palatine plate, 
so as to do as little damage as possible to the appearance of 
the face. 

Tumours of the Soft Palate may be dermoid and congenital, 
as in a case shown at the Pathological Society in April, 
1881, by Dr. Hale White, in which Mr. Morrant Baker 
removed the growth with a ligature ; or may be papilloma- 
tous, as in the case of a healthy girl, aged eighteen, who 
came to the Dental Hospital, Leicester Square, to have some 
teeth stopped ; on examining her mouth, Dr. Arkovy noticed 
a growth attached to the soft palate. It was pedunculated, 
hanging down beyond the margin of the left velum, and had 
a warty appearance ; he snipped it off with scissors and 
rather free luemorrhage followed. 

The growth was about half an inch long by one-sixth 
of an inch broad, the pedicle being about one- eighth of an inch 



TUMOURS OF THE PAL.iTE. 253 

thick ; it was of the same colour as the siuTouncling mucous 
membrane, and the surface was composed of enlarged 
fungiform and filiform papillae. On a longitudinal section 
it was seen to be composed of compound papillae branching 
off from a common root or base, each offshoot being com- 
posed of dilated blood-vessels, surrounded by a very small 
amount of connective tissue, and enclosed by a thin layer of 
mucous membrane, on which were several layers of epithelium 
cells of the pavement variety. 

In 1879, I had under my care a lady with a very 
suspicious tumour of the soft palate, which I feared would 
prove to be sarcomatous. On incising it, however, I was 
able to enucleate with the finger what proved to be an 
adenoma or hypertrophy of the glands of the soft palate, 
contained in a distinct cyst, which I was also able to with- 
draw. The patient has remained in perfect health to the 
present time. 

In the following year I saw, with Sir J. Paget, a child 
aged seven, with a tumour presenting almost precisely 
similar appearances, but upon cutting into the growth it 
proved to be a sarcoma with extensive attachments which 
did not admit of removal. The growth steadily increased 
and destroyed life in six months. 

Looking back at these two cases, I find it impossible to 
give any symptom by which they might have been distin- 
guished; but the duration of the growth, if it can be accurately 
ascertained, would doubtless help at arriving at a just 
conclusion. 

A case of medullary tumour of the soft palate in which 
the tumour was excised with temporary relief, is recorded by 
Mr. Langton in the Clinical Society's Transactions, vol. iii. 



254 



CHAPTEI^ XVII. 

EriTHELIOMA OF THE GUMS AND ANTHUM. 

E'pitliclioma of the gums, as commonly met with, cannot 
properly be included among the epulides, since it is the 
exception for there to be any out-growth or tumour in the 
early stage of the disease. A ragged ulceration of the gum, 
supposed to be dependent upon some tooth, and probably 
tlie direct result of long-continued irritation, is noticed, but 
the pain is not marked and the inconvenience is slight. 
Careful observation will soon detect a tendency of the 
ulceration to spread both towards the tongue and the cheek, 
and by this time, probably, induration of the base of the 
ulcer may be detected where it touches the softer tissues. 
The importance of prompt and thorough interference cannot 
be too strongly impressed upon members of the dental 
profession, by whom cases of epithelioma are most generally 
seen in the early stage. In a recent case of ulceration of 
the gum, simple treatment may fairly be tried for a week or 
ten days, but if the ulcer still remains unhealed, and more 
particularly if it is increasing, surgical aid should at once 
be summoned. The frequent application of the solid nitrate 
of silver to an ulcer which fails to heal readily, is worse 
than useless. The treatment of an epitheliomatous ulcer 
consists in thoroughly destroying it, with the tissue around 
for some distance. In slight or doubtful cases thorough 
application of the strongest nitric acid, the acid nitrate of 
mercury, or better, the actual cautery, may be sufficient to 
ensure a healthy cicatrization ; but even then the part will 
require careful watcliing, in order that any fresh development 
may be promptly attacked. Unfortunately the disease has, 



EPITHELIOMA OF THE GUMS. 25 5 

ill the majority of cases, already invaded the alveohis, as is 
shown by the swelling of the gum and the loosening of the 
teeth, and, when this is the case, free removal of the Lone 
must he undertaken. A vertical cut with a narrow saw 
being made through the whole depth of the alveolus well 
beyond the disease, the cross-cutting bone-forceps may be 
used, or the saw applied horizontally to remove the 
diseased portion, as is shown in fig. 128, taken from 
Fergusson. The danger of course is that the disease may 



Fig. 128. 




have penetrated more deeply than appears into tlie bone, so 
that recurrence is apt to take place rapidly from the 
epitheliomatous elements left behind. Should this occur, 
there must be no hesitation in removing the whole thickness 
of the bone, and in the incisor region the resulting incon- 
venience is much less than might be anticipated, the 
muscles attached to the two halves of the jaw forcing them 
together, so that tough fibrous, if not bony, ujiion takes place 
in the position of the original symphysis. 

Some years ago a man was sent to me l)y Mr. Harding 
with an undoubtedly epitheliomatous growth springing from 
the gum in the incisor region. This I removed by sawing 
the lower jaw horizontally below the level of the alveolus, 
but, the section not proving quite healthy in appearance, I 
thought it advisable to take away the whole thickness of 
the jaw in this region. The patient made a good recovery, 
with firm union between the two segments of the jaw, and 
I have not heard of any further recurrence. 

An equally satisfactory case has come under my frequent 



256 EPITHELIOMA OF THE GUMS. 

observation during the last three years, in the person of a re- 
tired officer of the army, who in 1879, after wearing a lower 
dental plate for some years, developed epithelioma of the gums 
and cheek. Professor Bowen Partridge, of Calcutta, removed 
the left half of the body of the jaw in December, 1879, and 
recurrence taking place at the chin, Dr. McLeod removed the 
right half in March, 1880, with the submaxillary glands of 
both sides. I first saw this gentleman in July, 1881, when the 
central portion of the jaw was of course gone, and there was 
a space of IJ inches between the halves of the bone. The 
tissues around were contracted, but perfectly healthy, and 
liis only complaint was a sense of tightness and want of 
saliva. During the last two years the portions of jaw have 
become more approximated, and the growth of a beard hides 
the want of chin ; and as nearly four years have now 
elapsed since the operation, the cure may, I presume, be 
considered permanent. 

In the Museum of the College of Surgeons are two speci- 
mens (2249 & A) of epithelioma of the alveolus in which a 
less satisfactory result followed. The patient was a gentle- 
man, aged fifty-four when he was sent to me by Mr. Weiss, 
with a well-marked epitheliomatous condition of the riglit 
lower alveolus, between the first molar and the canine teeth, 
which had been noticed six months. In addition, a well- 
marked ichthyotic condition of the mucous membrane of the 
floor of the mouth extended along the inner side of the body 
of the jaw and beneath the tongue. In September, 1880, I 
burnt away the whole of the affected mucous membrane with 
Paquelin's cautery, and having deeply notched the alveolus 
with the saw, I clipped out the affected portion with bone- 
forceps. Two months later the disease began to show itself 
on the inner side of the jaw, and in April, 1881, I removed 
the part affected very freely, cutting away the whole thick- 
ness of the bone from the second molar of the right to 
the second incisor of the left side, with the adjacent 
lymphatic gland, the section of bone being apparently 
healtliy. Eecurrence took place, however, shortly, and in 
November I removed a further portion of the left side of the 



EPITHELIOMA OF THE ANTRUM. 257 

lower jaw up to the first molar tooth (College of Surgeons' 
Museum, 2249). Notwithstandmg this complete removal of 
the disease, it returned in the soft parts beneath the tongue, 
large masses protruded into the mouth, and the patient sank 
in November, 1882. 

Both in this and in other similar cases I have been dis- 
appointed with the operation of removing solely the alveolus,. 
and am inclined to adopt more radical measures at first in 
future, being encouraged to do so both by the great success 
of the officer's case already mentioned, and by a case occur- 
ring in University College Hospital, the details of which 
will be found in the Appendix (Case X.). 

Epitlidioma of the Antrum, of the squamous variety, is a 
very insidious disease, which gives rise to the formation of 
no tumour of the face, but slowly destroys the antrum and 
spreads thence in all directions. It was first described, from 
the clinic of M. Verneuil, by M. Eeclus ('' Progres Medical," 
1876), who termed it very aptly epithelioma tirihrant (bur- 
rowing or boring epithelioma), and attention was called to 
it by Mr. Butlin in 1881. I had at the time two cases of 
the kind under observation, one in hospital, which was at 
first thought to be epithelioma of the palate, but in which 
the antrum was found extensively affected, and the other in 
private, wdiich was a good typical example of the disease. 
Tlie patient, aged sixty-six, had a troublesome and loose 
upper molar tooth, for which he consulted a well-known 
dental surgeon in the West of England, who extracted it,. 
bringing away a soft growth attached to the fangs. The 
opening was found to communicate with the antrum, and 
shortly a fungus growth protruded, and there was a good 
deal of discharge. The case was regarded as one of disease 
of the antrum, which was well syringed out, but the palate 
became more involved and the cheek somewhat swollen. 
Wlien I saw the patient in September, 1881, a month after 
the extraction of the tooth, there could be no doubt of its 
serious nature. Under chloroform I was able to pass my 
finger through the fungus completely into the antrum, which 
was widely affected. Turning up the lip without incising: 

S 



258 EPITHELIOMA OF THE ANTRUM. 

it, I was able with saw and bone-forceps to remove the floor 
of the antrum, which shows very well the disease (College 
of Surgeons' IMuseum, 2247). I then removed the back of 
the antrum, but the orbital plate being apparently healthy, 
I contented myself with scraping it freely and applying the 
chloride of zinc paste, the age of the patient forbidding 
removal of the whole upper jaw. Eecurrence took place, 
and I again scraped away the growth and applied the zinc 
paste, but the disease again made progress, and the patient 
died, worn out, within a year of the first appearance of the 
disorder. 

Mr. Butlin's case is very similar {Pathological Society's 
Transactions, 1881), and was that of a man aged sixty-two, 
who, after pain in the jaw, found a fistulous opening in tlie 
palate, from which a foul discharge proceeded. The finger 
was passed easily into the antrum, and the cavity was cleared 
out, and, upon recurrence taking place, the upper jaw was 
removed, but the patient sank on the fifth day. Mr. Butlin 
has recorded another case under Mr. M. Baker {Path. Trans., 
1882), in a woman of fifty-eight, with a bulging out of the 
right cheek and an opening from the palate into the antnim. 
The upper jaw was removed, but the disease was found to 
have already spread beyond it, and the patient died ex- 
hausted after a few days. 

The disease appears so insidiously and spreads so rapidly 
to the deeper parts tliat its prompt recognition is of the 
greatest importance, and it may, I think, be lield that the 
attachment of any growth to the fangs of extracted teeth 
should excite suspicion as to the presence of serious disease 
within the antrum. M. Iieclus, in the paper referred to, 
goes so far as to suggest that the disease originates in one 
of the periosteal cysts of the fangs of the teeth already 
described, but it seems more probable that it starts from the 
socket of a tooth, and derives its squamous character from 
the palate. 

The treatment is unsatisfactory, because tlie age of the 
patient forbids extensive operations, such as would be neces- 
sary for the removal of the upper jaw. In my own cases. 



EPITHELIOMA OF THE ANTRUM. 259 

in which I was content to operate from the mouth, the patients 
survived for some months, whereas in the two cases recorded 
by Mr. Butlin, in which the jaw was removed, the patients 
rapidly sank. 

Mr. G. Lawson has recorded (Clinical Society's Transac- 
tions, 1873) a case of this disease, in whicli he adopted a 
bolder, and apparently more successful treatment — viz., to 
destroy the skin over the growth and the disease itself with 
the actual cautery, and then to apply caustic paste freely so 
as to obtain large sloughs. The patient was sixty-five, and 
made a good, and it is believed, permanent recovery. Of 
course there is the permanent deformity to be considered, 
but, after all, this is a slight drawback if a cure can be 
obtained, and, as regards immediate danger to life, Mr. 
Lawson truly remarks, " it must be borne in mind that 
patients advanced in life stand cutting operations very badly, 
whilst they will bear, with but little shock, the destruction 
of large growths by escharotics." 



B 2 



260 



CHAPTEE XVIII. 

NON-.MALIGXAXT TUMOUKS OF THE UPPER JAW. 

Fibroma, Enclwndroma, Osteoma. 

With regard to the statistics of tumours of the upper jaw^ 
I shall content myself with quoting 0. "Weber, who has 
collected 307 cases from the following sources : — 183 cases 
tabulated by Heyfelder ; 36 recorded by Liicke from Lan- 
genbeck's clinique ; 17 reported in the Medical Times and 
Gazette (Sept. 3, 1859) ; and 71 cases either observed by 
himself in Wutzer's clinique, or occurring in his own prac- 
tice. Of the above cases there were : — 

Osseous tumours 32 

Vascular tumour 1 

Fibrous tumours 17 

Sarcomatous tumours 84 

Enchondromatous tumours 8 

Cystic tumours 20 

Mucous polypi 7 

Carcinoma 133 

Malanosis 5 



307 



In commenting upon this table, Weber very justly re- 
marks that doubtless the list of cancerous cases is exag- 
gerated, and suggests that a fair estimate would be gained 
by allotting rather more than a third of the whole number 
to sarcomatous (simple) tumours ; less than one-third to 
the cancerous ; and the remainder to the osseous tumours^ 
cysts, &c. 



FIBROMA OF THE UPPER JAW. 261 

It must be borae in mind, however, tliat modern methods 
of investigation have shown that the okl classifications are 
frequently based upon erroneous data, so that a re-arrange- 
ment of tumours of the jaws has become necessary, and will 
be attempted in the following pages. 

Fibroma. — This closely resembles the fibrous tumours 
found in other parts of the body, and especially in con- 
nection with the uterus. It is dense in structure but not 
unfrequently lobulated, and on section, slender bundles of 
intersecting fibres may occasionally be traced in them, of 
which there are good examples in the Museum of the College 
•of Sm'geons. The fibrous tumour usually springs from one 
of two situations, either the interior of the antrum or 
from some portion of the alveolus. In both cases it is 
intimately connected with the periosteum, in this respect 
resembling epulis. Occasionally the growth appears to 
follow some slight injury, as iu the case of a lady, a patient 
of Dr. Neale, from whom, in 1870, I successfully removed a 
fibrous tumour occupying the interior of the antrum, which 
had followed a blow given by her child, and which may have 
been a fibrous odontoma (p. 267). The fibrous tumour grows 
slowly but surely, involving in its progress the surrounding 
structures. When arising in the antrum, it first expands 
the walls of that cavity, bulging out the face and forming 
tumours in the palate and floor of the orbit, and subsequently 
produces absorption of the osseous walls and spreads un- 
checked in all directions. The foUow^ing description of a 
specimen in St. George's Hospital Museum gives a good 
idea of the ravages of such a tumour : — " Fibrous tumour 
growing from the antrum, and making its way by the 
absorption of the walls of that cavity in different directions. 
It projects upwards into the orbit, destroying the floor of 
that cavity, and protruding from its inner margin forwards 
on to the cheek. It has also destroyed the anterior wall of 
the antrum, and displaced the malar bone forward and out- 
ward ; inwards it projects into the nose beneath the middle 
turbinated bone, and downwards it makes its appearance on 
the under surface of the alveolar process in the form of a 



262 NON-M ALIGN ANT TUMOURS OF UPPER JAW. 

rounded mass, destroying the floor of tlie antrum in the 
neighbourhood of the front molar tooth. Behind, the 
tumour appears in the zygomatic fossa by the absorption of 
the outer part of the tuberosity of the superior maxillary 
bone. The tumour is composed of circular nuclei of various 
sizes, and spindle-shaped fibres. The patient from whom the 
specimen was taken, William H., died of ararchnitis, and 
softening of the corresponding part of the brain. " — Ccvtalogue 
of St. Georfies Hospital Mnseurn (II. 160). 

When it arises from the alveolus, a fibrous tumour may 
encroach on both the facial and the palatine surfaces of the 
jaw, crushing in the antrum although not invohdng its in- 
terior. Of this a good example is seen in a preparation 
(2238) in the College of Surgeons, of an upper jaw removed 
by Mr. Liston. Here the tumour which is affixed to the 
alveolar border, near the molar teeth, extends inwards so as 
to cover the palatine portion of the jaw, and outwards so 
as to conceal all the bicuspid and molar teeth, with the 
exception of the last. The walls of the antrum are pressed 
inwards, but its interior is healthy. The patient was a 
woman, thirty years old, and the tumour was observed four 
years before its removal, which was successful. On the 
other hand, fibrous tumours, though commencing in the 
alveolus, may secondarily involve the antrum when they 
have attained considerable size, producing complete absorp- 

Img. 129. 




tion of its walls, and projecting into the nose and through 
the palate. Of this a preparation in the College of Sur- 



FIBROMA OF THE UPPER JAW. 



263 



geons' Museum (2236), of an upper jaw, also removed by 
Mr. Liston, affords a good example. Here the patient was 
only twenty- one, and the growth first appeared on the 
outer side of the gum of the left upper jaw four years before 
the operation. It was cut off six months after its first 
appearance, but returned, and eighteen months after was 
removed, with a portion of the alveolar process, but reap- 
peared in a few weeks. Fig. 129, from Liston's " Practical 
Surgery," shows the growth after its removal, and figs. 130 
and 131 show the patient before and after the operation. 
It may be noticed here, as in the case of a large epulis, 
that disease of the upper jaw often closely resembles, exter- 
nally, a tumour of the inferior maxilla. 



Fig. 130. 



Fig. 131. 








The case is given by Mr. Liston in his paper on Tumours 
of the Jaw, in the Medico- Chirurgical Transactions, vol. xx. 

The enormous size to which fibrous tumours of tlie upper 
jaw may grow without destroying the patient, is well seen 
in the accompanying drawing (fig. 132) of Mr. Liston's 
celebrated case of Mrs. Frazer, from whom that eminent 
surgeon successfully removed the growtli. The timiour is 



264 NON-MALIGNANT TUMOURS OF UPPER JAW. 



preserved in the Museum of the College of Surgeons (2241), 
and its diameters are, vertically, seven inches ; transversely, 
seven inches ; from before backwards, nearly six inches. Con- 
trary to the ordinary practice, a portion of the integument 
WAS removed with the tumour, measuring twelve inches in 
length and ten in breadth, and this left a gap in the skin 
of the face upon the patient's recovery, a point wliich will 
be again referred to. The OTowth of this tumour was 
connected -apparently in a curious way with the performance 
of the uterine functions. The patient was forty years old, 
and the tumour began to grow six years before its removal, 
in consequence of a blow in the region of the antrum. Its 

Fig. 1,3'2. 




progress at first was slow and not painful, but at the end of 
two years a distinct tumour was felt in the cheek. During 
the next two years it grew rapidly, especially during a period 
of gestation, but still without much pain. In the fifth year 
of its growth she bore a second child, after which the cata- 
menia ceased to flow, and the tumour was subject to monthly 
augmentations of its vascularity, and slight haemorrhages 



FIBROMA OF THE UPPER JAW. 265 

occurred from its inner, though not ulcerated, surface, and 
from the adjacent parts of the gum. The case is given in 
detail in ]Mr. Liston's paper already referred to. 

A remarkable feature, noticed in a case of fibrous tumour 
of the antrum, in a young man of eighteen, under the care 
of Sir J. Paget, in I860, was a distinct pulsation in a portion 
of the tumour which projected into the orbit. The pulsa- 
tion was slight but decided, and was synchronous with the 
radial pulse. The case was clearly not one of malignant 
disease, but proved to be an ordinary fibrous tumour upon 
removal. No satisfactory explanation seems possible of the 
case, which I believe to be unique. Suppuration has oc- 
curred in connection with fibrous tumours of the jaw,»but 
only, I believe, when they have been punctured with a view 
to exploration and diagnosis. Of this the tumour removed 
from Janet Campbell and preserved in the Museum of the 
College of Surgeons (2239), is an example. Simple fibrous 
tumours occasionally recur after removal, but it is doubtful 
whether in these cases the whole of the disease has been 
eradicated. According to 0. "Weber they are usually con- 
nected with the lining of tlie Haversian canals of the sur- 
rounding bone, and though he believes that these processes 
may sometimes be effectually detached, he advises the prac- 
tice ordinarily followed of removing a portion of bone. 

I think it right to mention here that all the specimens 
removed by Mr. Listen, and referred to in the foregoing 
pages, have, in the new catalogue of the College of Surgeons* 
Museum, been placed among the sarcomata, on what I cannot 
but regard as insufficient grounds. In the first place, forty 
years' soaking in spirit prevents anything like a reliable 
microscopic examination, and the presence of a few cells 
scattered among the fibres of a tumour are no proof tiiat it 
is not a hbrous tumour ; and, secondly, the clinical history 
of all these cases is that of a simple growth, which once 
removed did not recur. I have therefore included them 
aiiiong the fibrous tumours, and if they are not so, it is very 
remarkable that there is no specimen of the true fibrous 
tumour of the upper jaw among the large number removed 



266 NON-MALIGNANT TUMOURS OF UPPER JAW. 

by Liston and preserved in the College of Surgeons' and in 
University College Museums. 

ribrous tumours of the jaw, like those in other parts of 
the body, and especially in the uterus, are liable to calca- 
reous degeneration, or, as is sometimes incorrectly stated, 
to ossific deposit. A good specimen of the kind is preserved 
in the Museum of St. Thomas's Hospital (I. 18), which is 
thus described in the Museum catalogue : — 

" An osteo-fibrous tumour of the antrum, removed by 
Mr. Solly. The tumour entirely filled the cavity of the 
antrum, the bony parietes of which have been absorbed to 
a considerable extent ; it protruded the cheek anteriorly, 
projected into the fauces posteriorly, pressed down the 
palate inferiorly, and extended to the septum nasi inter- 
nally. Its firmest point of attachment is to that part of 
the antrum corresponding to the roots of the first molar, 
canine, and incisor teeth. The tumour is of a rounded form, 
and has a smooth external surface ; its section presents very 
much the appearance of a fibrous tumour of the uterus of 
slow growth, and contains an abundance of bony deposit. 

" From a boy, aged seventeen. The existence of the tumour 
was discovered only ten months previous to its removal, 
when the face began to swell, the swelling being accompanied 
by pain. No untoward circumstances followed the opera- 
tion, and the boy left the hosp)ital quite well. The deformity 
was very slight. Five years after the operation the boy was 
in capital health." IMore complete details of the case will 
be found in Mr. Solly's " Surgical Experiences," lecture 41. 

A thin section of this tumour has been dried and pre- 
servedj in order to show the amount and distribution of the 
calcareous matter (I. 19). 

A remarkable example of calcareous degeneration of a 
fibrous tumour occurred in the practice of Sir W. Fergussou, 
and the preparation is now in the Museum of the College of 
Surgeons (2242). It is a fibrous tumour of the left upper 
jaw, of some years' growth, from a woman aged fifty, con- 
taining numerous calcareous particles and acicular crystals^ 
and in addition, enclosing a suppurating cavity, in which was 



FIBROMA OF THE UPPER JAW. 267 

a mass about an inch in diameter, found by Dr. Goodhart 
to consist of acicular crystals of mineral matter, entangling 
in places nucleated and shrivelled cells. This is clearly an 
example of extreme calcareous degeneration undergoing 
necrosis. 

With regard to the causes giving rise to fibrous tumours 
of the upper jaw thei'e is much obscurity, though there is 
little doubt that they in many cases originate in some irri- 
tation due either to a blow, or more frequently to the 
presence of decayed teeth ; and the latter may give rise to 
a tumour commencing in the alveolus itself or within the 
antrum, the lining membrane of which is irritated by the 
fangs of the diseased teeth. Bordenave strongly insisted 
upon this, and since his time most surgeons have taken the 
same view. Stanley mentions a case which occurred to Mr. 
Luke, in which a black, carious tooth was found imbedded 
in a fibrous tumour of the upper jaw, and other cases of the 
kind have occurred, although the event is more common in 
the case of the lower jaw. 

Since the publication of the first edition of this work 
M. Broca, in his "Traite des Tumeurs" (Paris, 1869), put 
forward the view that many cases of fibrous and fibro- 
cellular tumour of both upper and lower jaw depend upon 
the growth of a tooth-germ, and these are included by him 
under the head of odontomcs emhryo-plastiqucs. There is 
no difference in structure by which these fibrous odonto- 
mata can be distinguished from the ordinary fibrous tumour, 
but according to M, Broca they are always encysted, and 
they occur only in young subjects, and before the last tooth 
is formed. Owing to their ready enucleation, these tumours 
show no tendency to recur. I have met with but one case 
which seemed in any way to support the views above given. 
A young married lady, a patient of Dr. Neale, had a tumour 
of the upper jaw, evidently due to expansion of the antrum, 
the walls of which crackled under pressure. Believing the 
swelling to be due to fluid, I punctured it, giving exit to 
only a small quantity of fluid, and discovered a tumour 
within. On laying open the antrum, I was able to enucleate 



268 NOX-M ALIGN ANT TUMOURS OF UPPER JAW. 

Avitli the finger a tumour which had very slight attach- 
ments, presented all the appearance of a fibroma, and 
on examination hy Dr. Bastian, was pronounced to be very 
rich in cell elements, and therefore likely to recur. Never- 
theless, the patient is now in perfect healtli, fourteen years 
after the operation. 

Eiicliondroma of the upper jaw is of uncommon occur- 
rence, but tlie jaw may become involved in cartilaginous 
tumours springing from other bones of the face. Of this 
there is an example in St. George's Hospital Museum 
(XVII. 66), taken from a young woman, who, seven years 
before her death, began to suffer from soft elastic tumours 
on the inner side of the orbits. Two years after, the right 
maxillary bone was fuller below the orbit than the left, and 
tlie right half of the bony palate was larger and more de- 
pressed than the other ; but in neither of these parts was 
there any softening. Gradually the eyeballs were protruded, 
and the sight was lost. Two years later, it was noticed that 
the superior maxillary bones projected nearly an inch beyond 
the inferior, so that she had some difficulty in masticating. A 
portrait of this patient is preserved in St. George's Museum. 
The tumour was found to project into the cranium, the orbits, 
the antra, and the nasal, zygomatic, and ptery go -maxillary 
fossee. All the fossse were quite filled up by the growth, and 
the bones of the face and orbits extensively absorbed. The 
hard palate was pressed downwards, so that the teeth on the 
two sides deviated from their natural line, and the left 
central incisor crossed that of the right side. Microsco- 
pical examination of the tumour showed it to be composed 
principally of cartilage. A full description, with a litho- 
graph of the preparation, will be found in tlie PiHholoyical 
Society s Transactions, vol. x. 

In the Museum of St. Bartholomew's Hospital is another 
post-mortem specimen of cartilaginous tumour of the face, 
from a lad of sixteen (XII. l/'ZS), occupying the situation of 
the superior maxillary bones, which are completely absorlted. 
Above, tlie tumour has extended through the left side of the 
base of tlie skull into its cavity, where it forms a large pro- 



ENCHONDROMA OF THE UPPER JAW. 26^ 

jection in the situation of the anterior lobes of the cerebrum ; 
below, it is united to the soft palate ; in front, it protrudes 
and distends the left nostril, and has caused the ulceration 
of a part of the integuments of the face. The outer surface 
of the tumour is nodulated, its interior, shown by the sec- 
tion, is formed of close-set nodules and masses of cartilage, 
partially and irregularly ossified, and in some parts inter- 
sected by layers of a softer, probably fibrous tissue. A por- 
tion of its external surface projecting below the left nostril 
has sloughed. This case is drawn in IVIr. Stanley's illustra- 
tions to his work on " Diseases of the Bones ;" and both it 
and the preceding preparation illustrate very well the ten- 
dency of cartilaginous tumours to invade all the surrounding 
structures, and to fill the several cavities. 

A remarkable case of recurrent cartilaginous tumour of the 
face, originating in the upper jaw, was under my own care, 
of which the following are the particulars : — The patient, 
aged thirty-four, was admitted into University College 
Hospital on the 1st of January, 1868, with a large tumour 
of the right side of the face. When about seventeen years 
of age he noticed a pimple on the right side of the nose, 
which increased pretty rapidly, and three months after 
(1851) he went into St. Thomas's Hospital, when Mr. Le 
Gros Clark operated, and removed a tumour as large as a 
walnut. He quite recovered, and was well for a few months, 
but within a year the tumour had returned. He was then 
admitted into King's College Hospital, under Mr. Partridge, 
who, in June, 1852, removed the tumour, which was of an 
osteo-cartilaginous character, oblong in shape, and of the 
size of a large walnut, projecting slightly into the antrum, 
and involving the nasal process of the superior maxillary 
bone, but in no way implicating the mouth or orbit. From 
this operation the patient made a good recovery, except that 
a small fistulous opening was left in the cheek. The man 
continued in good health until 1857, when he went to 
America, and soon after arriving there he found the tumour 
beginning to appear again, and in 1860 Professor Gunn 
operated at Anne Harbour, in the state of Michigan, and 



270 NON-MALIGNANT TUMOURS OF UPPER JAW. 

removed the entire right upper jaw. The tumour, however, 
began to grow again rapidly, and projected on the face. The 
surgeons at Maple Eapids, where he lived, wanted to operate 
again, but the patient declined, and returned to England in 
1865. Soon after this an abscess formed in the upper part 
of the tumour, which was lanced with great relief, but the 
incision thus made had never closed, owing to the stretching 
of the skin by the tumour. 

The patient's appearance on admission was most unsightly 
(fig. 133), the right side of the face being greatly disfigured 
by a large tumour, by whicli the eye was thrust completely 

Fig. 133. 




aside, but without loss of vision. Immediately to the inner 
side of the eye was an open granulating sore of the size of 
a florin, the result of the incision for the evacuation of matter 
already referred to. The tumour appeared externally to con- 
sist of two portions, separated by a horizontal sulcus, at the 
bottom of which the fistulous opening resulting from the 
second operation was still visible. The upper and more 
prominent portion liad invaded the orbit, reaching to its 



ENCHONDROMA OF THE UPPER JAW. 271 

iipper border, and extending beyond the middle line of tlie 
nose. A small portion of this had, within the previous two 
months, projected through the left nasal bone. The lower 
portion of the tumour involved the ala of the nose and 
adjacent portion of the cheek, both of which were mucli 
distorted ; on a small projecting portion of this the skin 
was adherent. Both nostrils were completely blocked, and 
had been so for months. "Within the mouth it was seen 
that the whole of the right side of the hard palate had been 
removed ; and in its place there was a smooth, red, oval mass, 
coming down to the level of the teeth of the opposite side. 
The scars in the middle line of the lip and on the cheek, 
resulting from former operations, were still visible. The 
tumour was solid and not tender to the touch, the most 
prominent point being apparently osseous. There was no 
enlargement of the glands in the neck or elsewhere, and the 
man appeared in good health. The tumour had made 
decided progress within the previous few months, and lie 
was anxious to have it removed, to wliich, after a consulta- 
tion with my colleagues, I agreed. 

On January 8, under chloroform, I made a curved in- 
cision below the eye to the side of the nose, from the 
extremity of which a vertical incision was carried down the 
face and round the ala of the nose ; and the lip was divided 
in the cicatrix of a former operation. The flap was then 
dissected back, and with it a hard prominent nodule of bone, 
which became detached from the bulk of the tumour. The 
tumour being thus exposed, I proceeded to enucleate it with 
the fingers, and by successive efforts removed in this way the 
upper part of the growth. The portion projecting into the 
mouth was found to be held by a firm 1jand of tissue in the 
position of the gum, and after dividing this I was able to 
tear out the growth, and also a portion projecting through 
the posterior nares into the pharynx. The wound having 
been well sponged out and the haemorrhage having abated, 
the portion at the inner side of the orbit was removed, and 
was found to project into the frontal sinuses, which (parti- 
cularly the right) w^ere considerably expanded. Witli one of 



272 NON-MALIGNANT TUMOURS OF UPPER JAW. 

Langenbeck's palate spatula I carefully cleared these out, 
scraping tlie walls, and t])en introduced a pledget of lint 
covered with a paste of chloride of zinc (to which a string 
was attached), in order to destroy any remaining portion. 
This was the only part from which the growth appeared to 
have arisen, the remainder of the huge cavity left by the 
removal of the growth being perfectly smooth and healthy. 
The septum narium was found to be completely pushed over 
to the left, and to have been destroyed at the upper part by 
a projecting lobule of the growth, which had pushed through 
the nasal bone. The ala of the nose included a small portion 
of the growth, which was removed, and also the bony nodule 
attached to the flap, the upper corner of which, being very 
thin and closely involved in the growth, was cut oft". The 
wound was sponged out with solution of chloride of zinc, 
and all haemorrhage having ceased without the application 
of any ligatures, the lip was brought together Mdth hare-lip 
pins, and the remainder of the wound with wire sutures. 
The edges of the gap caused by the opening of an abscess 
some months back were brought together, but finding that 
this prevented the patient closing his eye, I subsequently 
removed these sutures. Collodion was painted over the 
wound, and the patient, who had a good pulse, was carried 
to bed. 

The patient made an uninterruptedly good recovery from 
the operation. Tlie wound was kept clean by syringing 
with Condy's fluid ; the plug of lint in the frontal sinus was 
removed on the third day after the operation, and the 
sutures on the eighth day, the incision being well united. 
The right eye, wdiich had been much displaced, began 
gradually' to recover its proper position. A fortnight after 
the operation, the patient was up and about the ward, and 
on Feb. 1 he went out for a walk. On Sunday, Feb. 2,. 
he again went out, the house-surgeon not being aware that 
there was a bitter east wind. This he felt a good deal, and 
the next day his face was noticed to be swollen and red. 
This had increased on the following day, when I saw hira, 
and it was evident that an attack of erysipelas was coming. 



ENCHONDROMA OF THE UPPER JAW. 273 

on. The patient was at once placed in a separate ward, and 
active treatment adopted. The erysipelas spread, however, 
and affected the throat, so that on Feb. 7 he was able to 
swallow but little, and was becoming rapidly exhausted. By 
the frequent use of the stomach-pump nourishment was 
introduced into the stomach, and he rallied for a day or two. 
Symptoms of pya3mia, however, now manifested themselves, 
and the patient rapidly lost ground, and after lingering for 
a week, died on Feb. 17. 

At the post-mortem examination^ the incisions in the face 
were cicatrized ; but the site of the tumour was granulating, 
and encrusted with mucus in parts. On removing the 
brain, it and the membranes were found perfectly healthy ; 
but the plate of bone between the frontal sinus and the 
cranial cavity was so thin, that it broke in the removal of 
the brain. There was no appearance of any remnant of 
tumour either in the frontal sinus or elsewhere, the walls of 
the large cavity left by its removal being healthy. In the 
thorax there was abundant evidence of pycemia, the lungs 
being filled with pyaemic abscesses. The tumour weighed 
nine ounces, and consisted of a loose cartilaginous material 
enclosed in a bony cyst, from which sjDicula were sent into 
the interior. At two points, and particularly at the most 
prominent portion of the tumour, the bone was of con- 
siderable thickness. The tumour was exhibited at the 
Pathological Society, and was referred to a committee of 
investigation, which pronounced it to be an enchondroma 
undergoing ossification, and presented the following report 
upon it : — " The portions examined consisted of a thin 
incomplete bony shell, coated by a fibrous membrane, and 
enclosing a soft tissue penetrated by bony spicula. The 
external membrane is composed of wavy bundles of common 
connective tissue, interwoven in planes generally parallel to 
the surface of the underlying bone, and enclosing groups of 
fat cells. Beneath this outer stratum there is a deeper 
layer, immediately resting upon the bone, composed chiefly 
of small, closely-packed cells, evidently the equivalent of the 
osteogenic layer of periosteum, and ministering as this does 

T 



274 NON-MALIGNANT TUMOURS OF UPPER JAW. 

to the growth of the bony shell. This latter is lamellated 
parallel to its outer surface, and it has a true osseous struc- 
ture. The enclosed soft tissue consists in greatest part of 
cartilage, the characters of which, though varying consider- 
ably, are everywhere unmistakable. The cartilage capsules 
in some situations are very large, and so crowded as nearly 
to exclude the intercellular substance, approximating to a 
colloid structure ; while in other parts the two tissues exist 
in nearly equal quantities, and here many of the capsules 
exhibit the concentric rings indicative of successive layers, 
which are not uncommonly seen in old and slow-growing 
enchondromata. The tumour belongs, no doubt, to the 
category of enchondromata." 

Probably the largest enchondroma of the upper jaw ever 
submitted to operation is one recorded by Mr, O'Shaugh- 
nessy, in his essay on Diseases of the eTaws (1844). The 
patient was a Hindoo, aged twenty-one, who had a tumour 
of the upper jaw, of a year's growth (?) which had attained 
an enormous size, as shown in the illustrations of the work 
in question, looking nearly as big as the patient's head. 
Mr. O'Shaughnessy removed the tumour, which weighed 
four pounds, and was nearly globular in form, having 
at its inferior surface a deep groove into which the lower 
jaw sank. On section it proved to be of dense fibro-carti- 
laginous structure, surrounded by a thin shell of bone 
in the greater part of its extent. The patient made a good 
recovery. 

These cases will serve to illustrate the leading features 
with regard to enchondroma. The disease appears ordina- 
rily early in life, springing from the surface of the bone, or 
from the antrum, and then making steady progress either 
externally, as in the last-mentioned case, or internally, as 
in the former ones. It produces absorption of the bone of 
the maxilla3 in its progress, and protrudes beneath the skin, 
which, however, it rarely, if ever, involves. Its rate of in- 
crease is ordinarily slow, and there must, I fancy, be some 
error in the statement of Mr. O'Shaughnessy 's patient, since 
it is difficult to imagine that a growth of that enormous size 



ENCHONDROMA OF THE UPPER JAW. 275 

could have been produced in one year. In the early stage, 
the enchondromatous tumour may possibly be got rid of by 
absorbent applications ; thus, Mr. Stanley (p. 147) mentions 
the case of a female, aged twenty-eight, who had a round 
tumour of the size of a hazel-nut on the front of the maxilla, 
which had been growing some months. This was ascer- 
tained, by the introduction of a needle, to be composed of 
cartilage with particles of bone dispersed through it. Under 
the local use of iodine two-thirds of the growth disappeared 
in the course of a few weeks. 

Such a result cannot be hoped for when the tumour has 
attained any size, but provided it is still confined to the 
maxilla, a cartilaginous tumour is a favourable one for re- 
moval, owing to its solidity and rounded form, and the ease 
with which it is isolated. The first case in which M. 
Gensoul removed the superior maxilla was for a tumour of 
this kind. Ordinarily perfect immunity from return is 
obtained, provided the whole disease has been extirpated. 

In many cases of enchondroma a certain amount of fibrous 
tissue is found mixed with the cartilage, and in some cases, 
particularly those of slow growth and of long standing, the 
fibrous has, to the naked eye, almost replaced the cartilagi- 
nous element. Of this an enchondromatous tumour, removed 
by Mr. Square, of Plymouth, in November, 1866, and kindly 
given me by that gentleman, is an excellent example. 

The tumour was of the size of an orange, and occupied 
the right superior maxilla of a woman, aged forty-seven. 
It had been growing ten years, and Mr. Square successfully 
removed it. The preparation, now in the Museum of the 
College of Surgeons (2216), and of which a section has 
been made, shows a surface closely resembling a fibrous 
tumour, but in which cartilage cells are readily found under 
the microscope. The preparation shows a deep groove in 
the buccal surface of the tumour caused by the teeth of the 
lower jaw. 

The ossific deposit, beginning at several separate points, 
which is not unfrequently found in connection with enchon- 
dromata of other parts of the body, may take place in 

T 2 



276 NON-MALIGNANT TUMOURS OF UPPER JAW. 

enchondroma of the upper jaw. A very excellent example 
of this was published by the late Mr. Maurice Collis, of 
Dublin (DuUin Quarterly Journal, Aug. 1867), and the 
appearance of the patient is well shown in the lithographic 
illustrations which accompany that paper. The patient was 
fifty years of age, and the disease dated from his fourteenth 
year. It grew slowly at first, but latterly had increased 
with considerable rapidity. The tumour was firm and hard, 
but painless until recently, when brow-ague was complained 
of. The sight of the left eye was lost, the left nostril 
occluded^ and hearing on that side somewhat dull. The 
tumour had expanded the chec^k, pushed up the floor of the 
orbit, and depressed the hard palate, Mr. Collis success- 
fully removed the growth, and the patient made a raj)id 
recovery. The following is Mr. Collis's description of the 
tumour : — 

" Much of it^ posterior part was removed piecemeal, but 
what remained was composed of two kinds of bone. The 
centre, which may be supposed to correspond to the antrum, 
is remarkably hard and close — white, with fine concentric 
rings, like ivory, which it also resembled not a little in its 
hardness. All round this, except above, lay a much larger 
mass of bone, distinctly and coarsely laminated, softer in 
textm^e, and enveloped in a very thin and strong layer of 
hard bone. This external mass was divided into two by a 
fissure which ran in an oblique cm^ve upwards and outwards 
into a very small, irregular space, filled with a mass of 
lining membrane, gathered up and jammed together. These 
two masses evidently corresponded to the middle and inferior 
spongy bones ; and the fissure and cavity represented that 
portion of the nostril which normally lies between these two 
bones. The growth commenced in the antrum, filled it, 
implicated its walls, extended to the spongy bones, developing 
itself layer over layer, until the entu-e nasal cavity was filled. 
It then continued to grow, producing the immense deformity 
already described. Originally it had probably been an en- 
chondi'oma, but as years advanced it ossified, beginning 
irom the centre. The outer layers of the new growth were 



OSTEOMA OF THE UPPER JAW. 277 

probably the most recent, as they contained some fragments 
of imperfect or degenerate cartilage. The whole was en- 
closed within a real bony layer, derived from the proper 
tissue of the spongy bones and of the walls of the antrum." 

In St. Thomas's Hospital Museum is a section of a skull 
(C. 196), showing a large tumour in connection with the 
superior maxilla, which appears to be an ossified enchon- 
droma. Superiorly the growth encroaches considerably upon 
the cavity of the orbit, and posteriorly it fills nearly the 
whole of the zygomatic fossa, extending as far back as the 
glenoid cavity. On the inner side it has involved the upper 
part of the nasal and the lower part of the sphenoidal 
sinuses ; whilst below it projects through the hard palate 
into the cavity of the mouth. 

During the winter session of 1867-68, my colleague, Mr. 
Beck, then Demonstrator of Anatomy at University College, 
found in the antrum of a subject an osseous mass filling up 
the cavity and attached to its outer wall, but giving rise to 
no external tumour either on the face or in the nares. On 
section the bone was white and dense, and upon microscopic 
examination the late Mr. Bruce considered it to be an 
instance of ossified enchondroma, the calcareous matter being 
more granular than in ordinary osseous growths, and the 
lacunae and canalicnli imperfectly developed. The prepara- 
tion is in my possession, and will serve to elucidate some 
points in connection with osseous tumours to be subsequently 
referred to. 

Osteoma. — The simplest form of osseous tumour of the 
upper jaw is an hypertrophy of the whole or of some portion 
of the bone. A case of Sir William Fergusson's has already 
been referred to (p. 216), in which this result was due to the 
presence of a tooth imbedded in the jaw ; but the same thing 
may happen without obvious cause. The tumour is slow of 
growth and painless, and upon removal shows no deviation 
from the ordinary structure of healthy bone. An example 
occurring in a girl of sixteen, from whom Sir William 
Fergusson successfully removed a growth of the kind, will be 
found in the Lancet, July 26, 1856 



tl78 NON-MALIGNANT TUMOURS OF UPPER JAW. 

In October, 1883, I had under my care in University 
College Hospital, a young woman, aged twenty-five, in whom 
a painless enlargement of the right upper jaw had been 
noticed for ten years, encroaching upon the palate and 
bulging out the cheek. I successfully removed the whole 
upper jaw, and on section the tumour was found to be 
simple bone, very dense, but otherwise healthy. One half 
of the specimen is in University College and the other 
in the College of Surgeons' Museum. 

In the Museum of Charing Cross Hospital is a remarkable 
specimen of osseous tumour of the upper jaw, removed by 
Mr. Hancock. The whole jaw seems expanded anteriorly, 
and the outer compact plate is perfect, except at the part 
immediately below the infra-orbital foramen, where it has 
given way, and the cancellous structure forming the interior 
of the tumour is seen. Mr. Hancock, in referring to this 
specimen {Lancet, Jan. 13, 1855), specially calls attention to 
the fact that the bone yielded to pressure to such an extent 
as to lead to some doubt as to its osseous nature. 

A still more remarkable specimen of the same kind is 
preserved in the Musee Dupuytren at Paris, which is shown 
in figs. 134 and 135 from the "Traite de Fathologie 

Fig. 134. Fig. 1;55. 




Externe," by M. Vidal de Cassis. It is connected with the 
left superior maxilla, being limited internally by the inter- 



OSTEOMA OF THE UPPER JAW. 279 

maxillary suture, beliiud by the pterygoid process, above 
and externally by the malar bone. The tumour encroaches 
considerably upon the cavity of the mouth, and reaches back 
as far as the front of the spine. Its form is bi-lobed, and 
in the deep sulcus betvi^een the lobes can be seen a molar 
tooth. All the other teeth of the jaw have disappeared, 
and there is no trace of their alveoli. The left orbit and 
nasal fossa are not sensibly diminished in size, but the cavity 
of the mouth is almost entirely occupied by the posterior 
lobe of the tumour. The lower jaw has, in this case, under- 
gone several remarkable alterations. It must at first have 
pressed upon the growth and produced the deep sulcus be- 
tween the lobes, but in its turn the tumour has reacted 
upon the lower jaw with the following eflect : — It has caused 
a double luxation of the jaw, the left condyle resting against 
tlie root of the zygoma and the glenoid cavity being filled 
with soft material. The teeth of the left side of the lower 
jaw have disappeared, and absorption of part of the coronoid 
process and the whole of the alveolus has taken place, so 
that only the base of this part of the bone is left. The 
outer surface of the tumour is smooth, and presents nume- 
rous vascular grooves of good size; at many points it is per- 
forated with holes. The vascularity of the other bones of 
the face does not appear augmented. 

In the Museum of Netley Hospital, which includes the 
preparations formerly at Fort Pitt, Chatham, there is a 
specimen of large osseous tumour of the upper jaw closely 
resembling that last described, but of smaller size. 

Besides this form of bony tumour, due apparently to an 
increase of the cancellous structure of the bone, specimens 
of tumour as hard as ivory have from time to time been 
met with. Perhaps the most remarkable of these is one 
described by Mr. Hilton, in the Guys Hosintal Eeiwrts, 
vol. i. p. 493, from the fact that the tumour separated spon- 
taneously from the face. The patient was a man aged 
thirty-six, who, twenty-three years before Mr. Hilton saw 
him, noticed a pimple below the left eye, close to the nose, 
which he irritated, and from that spot the tumour appears 



280 NON-MALIGNANT TUMOURS OF UPPER JAW. 

to have originated. The tumour iu its growth displaced 
the eyeball, giving rise to excruciating pain, which subsided 
on the bursting of the ball. It began to loosen by a process 
of ulceration around its margin six years before it fell out, 
which event was unattended by either bleeding or pain. The 
tumour weighed 14| ounces. It was tuberculated exter- 
nally, and an irregular cavity existed at the posterior part. 
A section presented a very hard polished surface resembling 
ivory, and exhibited lines in concentric curves enlarging as 
they were traced from the posterior part, The huge cavity 
left by the tumour was bounded below by the floor of the 
nose and antrum, above by the frontal and ethmoid bones, 
internally by the septum nasi, and externally by the orbit, 
which had been considerably encroached upon by the 
tumour. This patient was alive in 1865, thirty years after 
the prolapse of the tumour. 

A case in many respects resembHng Mr. Bilton's case 
was under the care of Sir William Fergusson, whom I had 
the opportunity of seeing operate upon it. The patient was 
a young man of twenty-one, who had first noticed the 
swelling on the left side of the face twelve years before. It 
grew for six or seven years, and then remained stationary. 
Two years before he had consulted a quack, who attempted 
to destroy the growth with caustic, and produced the large 
hole seen in the lower part of the tumour (fig, 136). 

On admission into King's College Hospital there was a 
swelling on the left side of the face about the size of an 
apple, extending from the eyebrow to a line less than one 
inch above the mouth. Internally, it encroached upon the 
nose, displacing it a little, the nasal bone being pushed for- 
wards and the left ala flattened on the columna ; the mass 
was felt by the finger in the mouth above the gums. The 
nostril on the same side was perfectly blocked up, the patient 
being totally unable to breathe through it. The right nostril, 
however, was quite free. Outwards, the tumour extended to 
the angle of the orbit ; the arch was, however, not displaced, 
but the tumour extended slightly above it. The floor of 
the orbit seemed displaced. The eyeball w\as seen imbedded 



OSTEOMA OF THE UPPER JAW. 281 

in the most prominent and central part of the tumour, and 
removed more than an inch from its natural position in the 
orbit, which Avas entirely blocked up by the mass. There 
was no extension into the pharynx. The tmnour was every- 

FiG. 136. 




where hard, with a slight blush over the surface. In its 
centre was a round opening, produced by the caustic applied 
two years previously, of about the size of a shilling, deep, 
and displaying in its floor black necrosed bone, and dis- 
charging pus. The patient said he had suffered neither 
headache nor pain in the tumour since its commencement, 
twelve years before, and that his sight liad been unaffected. 
Sir William Fergusson operated upon this patient on No- 
vember 30j 1867, and succeeded in removing the whole of 
the prominent tumour, weighing 1 0^ ounces, which consisted 
in all its anterior part of nodulated bone as hard as ivory, 
and posteriorly, of very dense ordinary bone mixed with a 
small amount of cartilage. A section showed an ivory-like 
mass closely resembling Mr. Hilton's specimen, connected 
with a mass of very much condensed bone. The tumour 
sprang apparently, as in the former case, from the upper 
part of the maxilla, and had invaded the antrum, orbit, and 



282 NON-MALIGNANT TUMOURS OF UPPEIl JAW. 

nostril. The palate was iu no way involved in the growth, 
and was preserved entire at the operation. Sir William 
FergLisson sawing horizontally immediately above it. Un- 
fortunately the patient sank rather suddenly, from inflam- 
mation of the lungs, on the fourth day. 

At the post-mortem examination, after removal of the 
brain, it was found that the affection of the bone involved 
the base of the skull^ there being a projection of the size of 
a hazel-nut from the sphenoid near the optic foramen. This 
involved the foramen and extended along the sphenoidal 
fissure, the optic, third, and fourth nerves passing through 
the condensed bone of which it was composed. The brain 
was unaffected (vide Lancet, Feb. 8, 1868). 

This specimen was exhibited to the Pathological Society 
of London and was reported upon by a committee. The 
report of this committee, drawn up by Mr. Hulke, which 
will be found in extcnso in vol. xix. of the Pathological 
Transactions, expresses an opinion that " the hard part of 
the tumour has been directly formed by the exogenous 
growth of successive layers of dense bony tissue under the 
periosteum, which opinion is confirmed by the absence from 
the hard tissue of the regular Haversian systems so charac- 
teristic of secondary bone." 

The reporters " did not find anywhere along the meeting 
line of the hard and spongy bony tissues anything resem- 
bling cartilage, and are disposed to regard the splitting of 
the tumour along this line as the result of violence, the 
place of the separation being determined by the different 
resistances of the two kinds of bony tissue. The intrusion 
of masses of the spongy tissue with the hard along the 
meeting line, and the occurrence of minute specks of spongy 
tissue in the midst of the hard tissue, suggest the direct 
continuity of the two tissues, and the microscopic appear- 
ances prove not only that this actually occurs, but also that 
the spongy tissue is formed by the rarefaction of the hard. 
For near its deep limits absorption spaces begin to appear 
in the hard tissue, and these, increasing in number and size 
and coalescing, produce large medullary spaces and cancelli. 



OSTEOMA OF THE UPPEK JAW. 283 

These are filled with a soft medulla carrying blood-vessels, 
and their walls consist of remnants of the hard primary bone 
and of new lamellne formed from the young medulla." 

It seems to me difficult to imagine that the condensed 
bone which extended into the skull, could at any time 
have been of an ivory nature, as this report implies. Pre- 
suming the ivory-like growth to have been deposited from the 
periosteum on the surface of the original maxilla, it is con- 
ceivable that the same action which led to this result may 
have led to a thickening and induration of the subjacent 
bone, which, in process of years, by simple extension, may 
have reached the sphenoid bone. 

In both these cases the tumour appears to have taken its 
origin in the upper wall of the antrum and to have grown 
forwards ; but tumours of the same kind have been found 
completely within the suj)erior maxilla, the anterior wall of 
which has been merely expanded by the growth behind it. 
Of this, two cases re]3orted within the last few years by M. 
Michon and Dr. Duka are good examples, and they will 
be elucidated by reference to a case recorded by M. De- 
marcpiay. 

M. Michon's case is reported in the 2nd volume of the 
M^moires tie la Sociit4 cle Chirurgie de Paris (1851) ; his 
patient being a man of nineteen, who had a large tumour 
of the right upper jaw, which had existed for three years. 
The tumour was rounded and hard, and had pushed up the 
eyeball considerably, and closed the right nostril, but the 
palate was not affected. M. Michon operated in Jan. 1850, 
by turning up a triangular flap of skin. He had intended 
to have removed the entire upper jaw, but having with con- 
siderable difficulty removed the front wall of the antrum, he 
found the tumour lying in the cavity, and connected only 
with the floor of the orbit and the vomer. After an opera- 
tion extending over an hour and six minutes, and without 
ani-csthetics, the tumour was at length removed. The whole 
of the vomer and a part of the maxilla came away with the 
tumour, which was a flattened sphere, or somewhat resem- 
bled a heart in shape. It weighed 120 grammes (1,800 



284 NON-MALIGNANT TUMOURS OF UPPER JAW. 

grains), and was deeply lobulated, particularly on the pos- 
terior aspect. A section showed concentric markings upon 
a surface of ivory, and microscopic examination demon- 
strated the lacuna} and canaliculi of true bone. The patient 
made a good recovery. 

Dr. Duka's case is reported in the Pathological Societi/s 
Transactions, vol. xvii., and occurred in a female native of 
Bengal, aged twenty-six, and on the right side of the face, 
which was not much deformed. There "svas a discharge from 
the right nostril, which was obstructed, and on examination 
a hard timiour was found within it, ichich was movable, but 
could not be extracted, and which had existed six years. 

Dr. Duka, failing to extract the tumour by laying open the 
nostril, resorted to the somewhat unusual proceeding of cut- 
ting a wedge out of the hard palate, and thus, after an 
operation of three-quarters of an hour, without chloroform, 
succeeded in removing the growth. The patient recovered. 
The tumour is preserved in St. George's Hospital Museum, 
and is figured in the Pathological Transactions, from which 
the accompanying illustration (fig. 137) is by permission 

Fia. 137. 




taken. It has an oblong shape, and is not unlike a middle- 
sized potato, with depressions and elevations passing irregu- 
larly over it. The upper part, which is believed to have 



OSTEOMA OF THE UPPER JAW. 285 

been in contact with the cribriform plate of the ethmoid 
bone, exhibits corresponding delicate depressions, with other 
deeper sulci in fronts behind, and on the sides, probably for 
the passage of blood-vessels. At the lower surface is a large 
nipple-like process, smooth throughout, This lay in contact 
with the palatine process, and it has the same dark appear- 
ance as the anterior part of the body which presented at the 
nostril. At the base of this process is a large liole piercing 
it quite through, and allowing the tip of the little finger to 
enter it. In this lacuna was a polypoid mass which con- 
tained a nucleus of cartilage, round and fiat like a small- 
sized lentil. It was this nipple-like prominence impinging 
upon the nasal process wliich prevented the removal of the 
tumour, without interfering with the superior maxillary bone. 
The whole bony mass, which is of a compact ivory-like 
character, weighs 1,060 grains : its long diameter is nearly 
three inches^ the short one an inch and two lines, and the 
longest circumference seven inches. The microscope gives 
evidence of structure closely resembling that of M. Michon's 
tumour. There are no distinct Haversian systems, but 
abundance of lacunar arranged around vascular canals. In 
some parts of the tumour the characters are very much those 
of simple ossified cartilage, clusters of large ossified cells 
being packed closely together. 

This case is remarkable from the fact that the attachment 
of the tumour had given way, and that it was therefore loose 
in the antrum. It would have appeared to be unique in this 
particular, but for the publication in the Gazette Meclicale 
cle Paris (April 20, 1867), of a very similar case of non- 
adherent exostosis, or osteoid tumour, by M. Demarquay, of 
which the following are the leading features : — 

A gentleman, aged fifty-three, in good health, but the 
subject of syphilis, had a swelling of the left side of the 
face, which had existed for twenty years. It gave no in- 
convenience except the disfigurement, until six months 
before he applied to M. Demarquay, when an abscess formed 
and burst, leaving a fistula. After this neuralgia came on, 
and other abscesses formed, rendering the face swollen and 



286 NON-MALIGNANT TUMOURS OF UPPER JAW. 

red. On examination several fistul?e were found both within 
and without the mouth. There was evidently suppuration 
within the antrum, probably due to a sequestrum. 

At the operation, on Jan, 4, 1867, it was found impossible 
to extract the sequestrum, and M. Demarquay therefore 
removed the entire maxilla, and the patient recovered. 

The jaw showed an increase of size and density; the front 
wall of the sinus was thrown forward, so as to present the 
segment of a sphere, and was thickened so that its resist- 
ance was increased. The posterior part was also enlarged, 
and had projections upon it, one of which also pushed up 
the floor of the orbit. There were numerous sinuses in 
various parts, through which pus escaped. 

On section, a white osteo-cartilaginous substance was found 
filling up the whole cavity of the antrum, but not attached 
to its walls. In some parts this was of a more fibrous 
character, whilst in others it was dense bone. In the centre 
was a large fragment of bone, of a blackish colour, and 
closely resembling a sequestrum. This was surrounded by 
some smaller portions, and by a cavity containing a quan- 
tity of pus, into which the sinuses could be traced. It was 
impossible to tell from which part of the wall the tumour 
had sprung. 

Here it will be observed that we have apparently an 
earlier stage of a growth, which if it had continued to in- 
crease, would no doubt liave developed into a dense osseous 
tumour, since it consisted in great part of cartilage in which 
ossification had already partially occurred. Dr. Duka's 
specimen also had some cartilage mixed with it, and its 
microscopic appearances showed evidence of* ossification of 
cartilage. The post-mortem specimen of ossified enchon- 
droma within the antrum in my possession, and already 
referred to (p. 277), sliows how slight the attachment of the 
growth to the wall of the antrum in these cases is. 

I think, therefore, it may be concluded that this class of 
bony tumours depends upon a form of ossification occurring 
in cartilage or enchondroma. 



287 



CHAPTEE XIX. 

SARCOMATOUS TUiMOUR OF THE UPPER JAW. 

Spindle- celled Sarcoma, Myeloid Sarcoma, Chondro-Sarcoma, 
Ossifying Sarcoma, 

Under tlie term Sarcoma^ modern pathologists include all 
tumours composed of tissue, which is either purely embryonic, 
or is undergoing one of the primary modifications seen in 
the development of adult connective tissue (Erichsen). 

In connection with the jaws various forms of sarcoma are 
found, many of which have hitherto been known by other 
names, and many recurrent growths formerly called cancers 
come properly into this class. 

The Spindle-celled Sarcoma is of frequent occurrence 
in the upper jaw, forming many of the specimens formerly 
indiscriminately named " osteo-sarcoma." It is usually of a 
yellower colour than the fibrous tumour and of softer 
consistence, and on section it exudes a serous fluid. The 
spindle-shaped cells are often of great length and size, and 
each cell contains one or more oval nuclei, the intercellular 
substance being homogeneous. 

Under the name of " albuminous sarcoma," Mr. Listen 
has described a case which appears to be of this kind, in tlie 
Lancet, Nov. 26, 1836, which proved fatal after removal of 
the tumour. The patient was twenty- four years of age, 
and the disease appeared to have originated in a blow, and 
grew with tolerable rapidity. The tumour, which is pre- 
served in the College of Surgeons' Museum (2202), is oval 
in form, its chief diameters being about three inches by two 
inches, and contained spaces in which was a glairy fluid, 



288 SARCOMA OF THE UPPER JAW. 

coagiilable by lieat. Mr. Lane successfully removed, in 1861, 
both upper jaws, together with the vomer, &c., which were 
involved in an " albuminous sarcoma,^' from a man aged 
forty-eight, whose case will be found in the Lancet^ Jan. 
25, 1862. The tumour inplicated both superior maxillary 
bones and filled both nostrils. It formed an extensive 
convex irregular swelling in the mouth, which pressed down 
the tongue. Very little bony material could be distinguished 
in the position of the palatine processes of the maxillary or 
palate bones, and the growth which occupied their place was 
soft and elastic, and was ulcerated in two or three spots of 
the size of a fourpenny-piece. The growth first showed 
itself within the left nostril three or four years previously, 
j)resenting the appearance of a nasal polj'pus, and was 
removed three times. 

In the same number of the Lancet is the report of a case 
of tumour, also removed by Mr. Lane, from a child of nine 
years, which presented much the same characters. The 
report states that portions of the growth, placed under the 
microscope, presented the characters of a fibro-nucleated 
structure, being composed of minute fibres, in which were 
disseminated numerous small oval nuclei about the size of 
blood globules, measui'ing from the four-thousandth to the 
three-thousandth part of an inch in diameter. 

In the Lancet for August 31, 1861, is the report of a 
remarkable case of fibro-cellular tumour of the jaw, under 
the care of Sir WilHam Fergusson, in which the patient was 
the subject of two tumours, one situated in the right cheek, 
the other in the antrum and roof of tlie mouth. The 
growths were, however, perfectly distinct from one another, 
and both were removed at a single operation, which was 
attended with the best results. Sir "William Fergusson had 
seen the patient twelve months before, and the disease then 
presented so malignant an aspect that he dissuaded her from 
undergoing any operation. Some months later, the disease 
in the mouth was found to be an ulcerated, sloughy-looking 
mass, and the finger could be readily passed alongside of it 
into the antrum. Perceiving that its progress bad been slow, 



SPINDLE- CELLED SARCOMA. 289 

and that it was within the reach of surgical aid, he thought 
lie would give her a chance of relief, more especially as there 
was no development of disease in any other situation, and 
the tumour in the cheek was quite distinct from that in 
the jaw. 

The report states that the softer part of the disease 
appeared, on microscopical examination, to consist mainly of 
a fibro-granular matrix, containing numerous corpuscles, 
round, regular, of uniform size, granular, and with no appear- 
ance of nuclei. The much firmer tumour of the cheek 
contained corpuscles of a similar character, with a large 
proportion of the fibrous element. 

The tendency to ulceration which was exhibited in this 
case is a marked feature of this form of disease, and not 
unfrequently leads to difficulty in solving the question of 
malignancy. It is seldom that in the case of the upper jaw 
the skin becomes involved in the disease, but in the lower 
jaw this frequently happens, and large fungous protrusions 
occur which may be mistaken for open cancer. The history 
of the case^ together with the absence of any enlargement 
of the lymphatic glands, is suflficient to mark the nature of 
the growth. 

In his paper on Osteo-sarcoma, in the fourth volume of 
the Dublin Hos'pital Reports, Sir Philip Crampton says that 
" in the earlier stages of the disease the tumour consists of 
a dense elastic substance resembling fibro-cartilaginous struc- 
ture, but the resemblance is more in colour than consistency, 
for it is not nearly so hard, and is granular rather than 
fibrous, so that it 'hrealcs sJiort.' On cutting into the tumour 
the edge of the knife grates against spicula, or small grains 
of earthy matter with which its substance is beset." The 
tumours described above corresjiond very closely to this 
definition, especially that of Mr. Liston, which is said to be 
" chiefly composed of a firm substance like fibro-cartilage, 
with spicula of bone." 

In his work on the ".Diseases of the Bones" (p. 283), 
Mr. Stanley mentions " fatty" tumours of the superior 
maxilla. He refers (p. 104) to a specimen in St. Bartho- 

U 



290 SARCOMA OF THE UPPER JAW. 

lomew^s Hospital Museum (I. 151), of wliicli the follo-sviiig 
is the description : — 

" Sections of a tumour which occupied the situation of the 
superior maxillary l)one, and was removed by operation. 
The whole of the natural structm-e of the superior maxillary 
bone has disappeared. The mucous membrane wliicli covered 
the palatine surface of the bone extends over a part of the 
tumour. The morbid gi'owth consists of a moderately firm 
fatty-looking substance, with minute cells and spicula of bone 
dispersed through it. 

" From a man, aged forty-six. The disease returned after 
the operation, and the patient died in consequence of haemor- 
rhage from ulceration of the internal carotid artery, which 
became involved in an extension of the disease." 

Tliis, as far as can be judged, would appear to have been 
an example of spindle-celled sarcoma or osteo-sarcoma, which 
had undergone fatty degeneration ; and the same may, I 
imagine, be said of the cases refeiTed to by Von Siebold as 
osteo-steatomata. The disease would appear to be a rare 
one, as it is not mentioned by most authors. 

The modern spindle-celled sarcoma includes both the cases 
formerly classed as recurrent fibroid tumours, and those which 
have been termed fibro-sarcomata, from containing numerous 
young cells, round or oat-shaped, betAveen the fibres. 

It is an undoubted fact that fibrous tumours do recur in 
the upper jaw after complete removal ; of this Mr. Liston's 
series of specimens, already referred to, gives more than one 
example, and it is probable that careful microscopic exami- 
nation would prove that some of them exhibit the peculiar 
" oat-shaped nucleated cells," described by Sir J. Paget as 
characteristic of the recurrent tumour. It is not surprising 
that these tumours should have been considered as examples 
of the ordinary fibrous tumour, since Sir J. Paget himself 
observes, in speaking of a well-marked specimen, " M'ithout 
the microscope, I should certainly have called it a fibrous 
tumour." 

In connection with this subject I may quote the following 
extract from the report upon diseases of the jaw, in the 



SPINDLE-CELLED SARCOMA. 291 

Medical Times and Gazette, Sept. 3, 1859 : — " The only 
example which we have to quote of recurrent fibroid tumour 
developed in connection with the jaws, is one in which the 
diagnosis of that variety of tumour and true cancer is by no 
means positive. It is that of a woman, aged tliirty-four, 
\inder Mr. Cock's care, in Guy's Hospital, at different times, 
for two or three years (1854 and 1856), The growth 
occupied the right antrum, and extended into the nose ; on 
several occasions ]\lr. Cock dissected up the cheek in front, 
laid bare the cavity, and gouged out the tumour and the 
bone to which it was attached. The parts always healed 
quickly, but the disease soon returned. The tumour had 
tlie microscope features of a recurrent fibroid, as distinct 
from those of a true cancer, and the fact that it continued 
to recur in the same place, but did not cause disease of the 
glands, is confirmatory of that diagnosis. The woman was 
very pallid and cachectic, but her cachexia did not exactly 
resemble that of cancer. We lost sight of lier towards the 
end of 1856, and do not know the final result of her case. 
Probably she has since died of her disease.^' 

In March, 1867, I had the opportunity of seeing a patient 
of Mr. Lawson's, a lady aged thirty-three, from whom, in 
the preceding May, that gentleman had removed a recurrent 
fibroid tumour of the left orbit. From this operation she 
perfectly recovered, but, four months before I saw her, the 
patient had found a small hard swelling of the left side of 
the hard palate. This rapidly increased, spreading back- 
wards into the soft palate, and forwards so as to press upon 
the incisor teeth. The swelling was irregular in outline, but 
with a perfectly smooth surface, and was so soft and elastic 
that it conveyed the impression of fluid, and had been punc- 
tured. Mr. Lawson removed the whole of the left side of 
the hard palate and as much of the soft palate as was in- 
volved in the disease, and the patient made a perfect recovery. 
Four months afterwards the patient again appeared, the 
disease having recurred on the right side of the hard palate. 
There was also a fibroid tumour in the parotid region, which 
had been present some years, and had now begun to increase 

u 2 



292 SARCOMA OF THE UPPER JAW. 

in size. Mr. Lawson removed the tumour of the palate with 
the gouge, inchiding all the periosteum involved by the 
growth, and excised the parotid tumour. The patient re- 
covered, and has had no further return up to the present 
time. The growths gave unmistakable microscopic evidence 
of their recurrent fibroid nature. 

Myeloid Sarcoma is found in the upper as well as in the 
lower jaw, in which latter position the specimen first de- 
scribed by Sir J. Paget arose. The occurrence of myeloid 
cells in specimens of epulis has been already referred to,, 
and it might naturally be expected therefore that the same 
characters might be discovered in tumours of the jaw. In 
fact. Dr. Eugene Nelaton, in a valuable treatise, published in 
1860, " Des Tumeurs a Myeloplaxes," says " la siege 
d'election des tumeurs k myeloplaxes est, sans contredit, 
dans les os maxillaires, particulierement au niveau de leur 
bord alveolaire," and supports his statement by quoting 
twenty-nine cases of the disease in this situation. 

The diagnosis of myeloid tumours of the jaw is by no 
means easy, since the bone is slowly expanded, much as it 
would be by a cyst, or by any benign tumour. If the 
disease originate on the exterior of the bone, or when 
springing from the interior, if sufficient absorption of the 
bone have taken place to allow the tumour to appear 
beneath the mucous membrane, the characteristic dark 
maroon colour of the tumour may be perceived. Cysts 
occasionally form in the substance of a myeloid tumour, 
and an exploratory puncture of these may yield fluid in 
which the characteristic myeloid cells may be discovered 
microscopically. 

^Myeloid disease occurs mostly before the age of twenty- 
five. Sir J. Paget {"Surgical Pathology," p. 524) quotes 
two cases of Sir William Lawrence's, occurring in the upper 
jaws of women of twenty-one and twenty-two years of age, 
the latter of which illustrates extremely well the recurrence of 
myeloid growths (of which there can be no question), and 
also the very curious fact that a tumour on the opposite 
side to that removed, and whicli presented appearances 



MYELOID SARCOMA. 



293 



exactly corresponding to it, spontaneously subsided. The 
specimen is in St. Bartholomew's Hospital Museum (1.459). 
Fig. 138 shows a patient from whom Mr. Canton removed 
a myeloid tumour in 1864. She was thirty-five years old, 
and the tumour appeared to have follow^ed a blow. It had 
been twice removed before slie came under Mr. Canton's 
care, and that gentleman successfully removed the left 

Fig. 138. 




superior maxilla with the tumour, a portion of whicli hung 
down into the pharynx. The tumour was brought before 
the Pathological Society of London, in December, 18G5, and 
the following is a description of the tumour, by Messrs. 
Bryant and Adams, to whom the specimen was referred : — - 
" The parts placed in our hands for examination consisted of 



294 SARCOMA OF THE UPPER JAW. 

the left superior maxillary bone, including its orbital plate, 
from the inferior surface of which appeared to grow a large 
tumour, which filled the cavity of the antrum, and projected 
forwards and inwards into the nasal cavity. There was also 
a second and loose portion, the size of a walnut, which 
appeared to liave been broken off during the operation, and 
was said to have projected posteriorly towards the pharynx. 
The external wall of the antrum was not expanded so fully 
as is usually found in tumours of the antrum. The tumour, 
which had been some time in spirit, was of a firm fibrous 
nature, and irregularly lobulated, and it had a dense capsule. 
On section, the structure presented a large amount of 
fibrous tissue, arranged in a curvilinear form, intermixed 
with other tissue not easily broken up. Microscopically 
examined, the tumour consisted of an abundance of fibrous 
tissue, which formed the stroma, containing in its meshes 
innumerable cells, generally of a circular or ovoid form, 
varying from two to three diameters of a blood-corpuscle, 
and some of a still larger size. The cells were all nucleated, 
usually containing several nuclei, and frequently presenting 
a granular appearance. Large compound cells were abun- 
dant in the posterior and softer lobe of the tumour, and a 
few elongated cells were seen amongst the fibrous tissue. 
These large compound cells presented very much the ap- 
pearance of the polynucleated cells met with in myeloid 
tumours." — Transactions of the Pathological Society, vol. xvii. 
The subsequent history of tliis patient is given as follows, 
in the Lancet of January 26, 1872, and it is remarkable 
that the tumour on one side should have had a character 
differing from that on the other : — " In June, 1871, she again 
presented herself at the Charing Cross Hospital with a large 
tumour filling up the antrum of the right upper maxilla, 
and extending forwards, causing a projection of the upper 
lij). Mr. Canton accordingly removed the remaining upper 
maxilla. The operation was perfectly successful, and pre- 
sented in itself no points of particular interest. The edges 
of the incision were brought together with silver sutures, 
and no dressing of any kind was used, the mouth being 



MYELOID SARCOMA. 295 

simply kept perfectly clean and sweet by the frequent use 
of Condy's fluid. Within a week of the operation she left 
her bed, and within three weeks she was discharged from 
the hospital. Five months later the j)atient wrote to say 
that she had enjoyed perfect health since she had left the 
hospital. On microscopic examination the tumour proved 
to be simply fibrous. It had been growing for a year 
before removal. Notwithstanchng that a great part of the 
framework of the face had been taken away, and that a 
portion of the orbital plate was removed at both operations, 
there was remarkably little deformity of the face. The 
patient had lost all power of muscular expression, but 
beyond this there was nothing to attract attention, except a 
slight falling in of the upper lip on the right side. There was 
no falling in of the nose, the raphe of what was the roof 
of the mouth deriving great support from a firm pseudo- 
palate, which had formed of cicatricial tissue after the first 
operation. The cicatrices of the incisions were scarcely 
noticeable, as they followed the natural lines of the face." 

Mr. Canton has obliged me with the portrait and history 
of a case of still more marked myeloid disease of the upper 
jaw, which was also under his care. The patient was forty- 
six years of age, which is decidedly advanced for the disease, 
and the tumour grew with unusual rapidity. Mr. Canton 
removed the jaw in Dec. 1866, and I had the opportunity of 
. seeing the patient in Jan. 1867, when he was quite well, but 
had still a small fistulous opening on the face. Dr. Tonge 
carefully examined the tumour (which is preserved in the 
Museum of Charing Cross Hospital), and has kindly fur- 
nished me with the following report upon it and upon the 
microscopic appearances it presented :— " The tumour was 
about the size and shape of a large hen's egg that had been 
flattened slightly in the transverse direction, and measured 
(after being in moderately strong spirit for some days) about 
two and three-quarter inches in length, from one and three- 
quarters to two inches transversely, and about one and a 
half inch in thickness. It was of firm consistence through- 
out, and on section presented a whitish appearance, with 



296 SARCOMA OF THE UPPER JAW. 

a small pink patch or two, and a wliitisli, creamy-looking 
juice could be scraped from the cut surface. The micro- 
scopical appearances of a portion of a thin section of the 
tumour, that had been preserved in glycerine and coloured 
with carmine, are represented in the accomi:)anying drawing, 
which was taken with the aid of the camera lucida. The 
fibrous element was much less abundant tJian the cellular, 
and consisted of white fibrous tissue, with numerous fine 
curling fibres of yellow elastic tissue, and many small oval 
and rounded nuclei were imbedded in the fibrous structure. 
The greater portion of the tumour seemed to be composed 
of cells. These were mostly of an irregularly-rounded form, 
often with pointed processes, and some shuttle-shaped and 
spindle-shaped, of a somewhat trapezoidal form, were not 
uncommon, while a few cells presented the character of 
those distinctive of myeloid tumours. All the cells con- 
tained one, and often two, very large and generally oval 
nuclei, with one, two, or three nucleoli, and a variable num- 
ber of oil globules. The myeloid cells observed were of 
irregular outline, and contained from three to five nuclei, 
with single or double nucleoli — one very large cell con- 
tained six nuclei. 

" These cells were not very numerous, but appeared suffi- 
ciently so to justify the application of ' myeloid' to the tumour, 
though, to the naked eye, and on a superficial microscopical 
examination, it presented many of the appearances of cancer." 

In the Museum of the College of Surgeons are two speci- 
mens (2245 and A), the two superior maxilhe of a woman, 
aged twenty-one, which were given me by Messrs. Andrews 
and Coates, of Salisbury, who removed them. The left upper 
jaw has been macerated, showing a calcified tumour springing 
from the anterior part ; the right jaw has a growth involv- 
ing the anterior portion extending into the nasal fossa. 
The growth in these cases was regarded by the operators as 
an example of scirrhus, but I am enabled by the kindness of 
Dr. Lush, of Weymouth, to correct this statement, by a record 
which he has of the microscopic details observed when the 
tumours were recent, as follows : — 



VASCULAll SARCOMA. 297 

" A section showed numerous spheroidal cells with one, 
two, or more nuclei, free matter and some compound cells." 
The tumour should therefore doubtless properly be regarded 
as myeloid. The history of the patient is the following : — 
Jane F., aged twenty-one, was admitted into the Salisbury 
Infirmary, July 24, 1858, for a tumour of the left upper jaw. 
The operation of removal of the left upper jaw was performed 
by Mr. Andrews, and she was made an out-patient Aug. 28, 
1858. She was readmitted on Oct. 1, 1859, under Mr. 
Coates, having a fortnight before perceived a small growth 
occupying the edge of the alveolar process at the site of the 
left upper incisor, which became rapidly exquisitely painful, 
and involved the alveolus of the right side, and also the 
upper lip. Mr. Coates removed the remaining right superior 
maxilla under chloroform, Oct. 13, 1859. The portion of the 
lip covering the small tumour (which was about the size of 
a hazel-nut) was also removed, and found to be infiltrated 
with disease. The patient was discharged cured Nov. 5, 1859, 
and was in perfect health in 1866. 

Vascular tumours of a non-malignant character, but 
closely resembling erectile tumours in other parts of the 
body, have been occasionally met with in the upper jaw, 
though the majority of the pulsating tumours of bone are 
examples of vascular sarcoma. Mr. Listen, in 1841, success- 
fully removed a specimen of the kind, which is preserved in 
University College, from a young man aged twenty-one. 
The tumour was of more than three years' growth, and pro- 
jected into the nares and pharynx, forming a tumour beneath 
the cheek ; but the preparation shows that the alveolus and 
all the lower and anterior part of the maxilla were not 
involved in the disease. The tumour was not painful, but 
frequent haemorrhages had taken place from its surface. The 
.case will be found in the Lancet, Oct. 9, 1841. Mr. Listen 
removed the jaw, cutting completely beyond the disease, and 
remarks concerning it {Lancd, Oct. 26, 1844) : — " It was a 
curious-looking tumour, and it struck me that it was of a 
fibrous character, not growing from the jaw, but involving 
it. Mr. Marshall some months afterwards discovered that 



298 SAKCOMA OF THE UPPER JAW. 

the wliole mass was erectile You will see that it 

is as complete and beautiful a specimen of an erectile 
tumour as any that I have yet shown you." 

The tumour, which is in the IMuseum of University College 
(684), is described as follows in the catalogue by Mr. Marcus 
Beck: — "A large tumour of the ptery go-maxillary fossa re- 
moved with the upper jaw. The specimen includes the whole 
of the maxilla except a narrow strip of its palatine process, 
and small portions of the nasal and malar processes, the 
whole of the lower part of the palate bone, and the lower 
portions of both pterygoid plates of the sphenoid, and the 
inferior turbinated bone. 

" The tumour, which measures about three inches in the 
antero-posterior direction, has grown from the posterior 
surface of the maxilla, and filled the spheno-maxillary and 
lower part of the temporal fossre, and has passed far back- 
wards under cover of tlie ramus of the inferior maxilla so as, 
on the inner side, to have projected within the pharynx ; 
and from the anterior part of the tumour a portion has 
grown forwards beneath the hard palate into the mouth. 
The posterior half of the tumour is deeply cleft into lobes. 
On the inner aspect of the parts a piece of the tumour has 
been cut away ; the divided surface has a uniformly open, 
cavernous structure, like that of the corpus spongiosum 
penis, the meshes of which are nowhere occupied by a solid 
substance, and probably allowed of the circulation of blood 
through them. The tumour is everywhere bounded by a 
dense layer of fibrous tissue. The cavity of the antrum is 
entirely unaffected." 

M. Gensoul also met with an erectile tumour springing 
from the antrum, in one of the cases from which he success- 
fully extirpated the upper jaw. 

Mr. Butcher, of Dublin, has described (" Operative and- 
Conservative Surgery/' p. 249) a case of successful removal 
of the right upper jaw, on account of a large fibro-vascular 
tumour springing from the antrum of a lad of sixteen. Nine 
months before admission he had had a polypoid growth re- 
moved from the nostril, "ivinsi rise to severe hicmorrhage. It 



VASCULAR SARCOMA. 299 

reappeared in a inontli, and increased, so that when he came 
under Mr. Butcher's care there was considerable deformity 
of the face, and the nostril was filled with the tumour, which 
projected behind the soft palate. After the boy had been 
in hospital a few days tlie tumour suddenly increased with 
great rapidity, and interfered so much with respiration and 
deglutition that Mr, Butcher at once removed the jaw, and 
the patient made a good recovery. 

The following is the description given of the tumour : — 
*' The structure of the tumour presented many interesting 
peculiarities. Its attachment and origin sprang from the 
outer part of the antrum. Not only was it incorporated 
with the lining membrane, but it likewise implicated the 
osseous wall. The surface from which it sprang in the 
recent state was softened, vascular, and pulpy, the upper 
surface of the tumour w^as lobulated wliere it encroached 
upon the orbit, and elevated its tloor ; the lobules were of 
various sizes — some very small, but each consistent in struc- 
ture, and invested by a dense capsule in a similar way to the 
larger masses of the growth. The entire tumour was re- 
markable for its great vascularity, which was more parti- 
cularly confined to the posterior and upper surface ; while 
on section the structure was dense by comparison, pale, 
eminently firm, and partaking of a fibrous matted nature. 
This integral arrangement was very manifest under close 
examination with the microscope, and cleared away the sus- 
picion which, on superficial inspection, might have been 
created of encephaloid disease being the synonym most 
applicable to the growth. There was a total absence of all 
nucleated cells, either globular, caudate, or spindle-shaped ; 
and, above all, the section of any part only yielded a minute 
quantity of serum or blood on pressure, and not the true 
succus of cancerous tissue. The tumour, though destructive 
to the neighbouring parts by pressure, yet did not appro- 
priate or incorporate them in its structure. This peculiarity 
of non-malignant growths was strikingly manifest in tlie 
present instance ; for by pressure, producing interstitial ab- 
sorption, the cancellated structure of the ethmoid and infe- 



300 SARCOMA OF THE UPPER JAW. 

rior spongy bones was attenuated and removed ; and by the 
same process the vomer was detached from its position — a 
few shreds of it being spared and hanging loosely on the 
sinistral surface of the tumour. The vascularity of the 
growth, though remarkable on the surface, yet did not per- 
meate its texture ; lience a tendency to degenerate by 
assumed depravity of action was lessened. Again, the vas- 
cularity of the surface will readily account for the repeated 
and profuse losses of blood — a point of great practical value, 
because placing the surgeon on his guard as to the impor- 
tance which should be attached to those repeated losses, in 
constituting a diagnostic feature confirmatory of malignant 
disease." 

Chondrosarcoma , in which spindle- or round-celled sarco- 
matous elements are mixed with the cartilage forming the 
bulk of the tumour occurs occasionally in the upper jaw, and 
is apt to be followed by secondary deposits in the lungs, 
this clinical fact distinguishing it from the ordinary enchon- 
droma. In 1879, I was consulted respecting a young lady 
who, two years before, had had removed from the floor of 
the orbit a small growth wliich grew from the orbital plate 
and displaced the eyeball. The growth recurred, and when 
I saw the patient both nostrils were completely blocked ; 
there was slight bulging of the antrum, and nobbly swellings 
of the size of a sixpence on the raphe of the hard palate on 
the left side, and another on the right side of the palate. 
The frontal bone also seemed affected. I advised against an 
operation, but another surgeon removed the upper jaw, and 
was unable to take away tlie whole of the disease, which 
proved to be chondro-sarcoma. 

Ossifying Sarcoma and Osteoid Chondro-sarcoma imply the 
occurrence of ossification in tumours containing sarcomatous 
elements, and include the cases hitherto described as 
" osteoid cancer." A good specimen of the kind is preserved 
in the Museum of the College of Surgeons (1712), of which 
the history with an accompanying drawing is recorded in Mr. 
Howship's " Surgical Observations." The specimen has been 
macerated, and the part which remains consists of an oval 



OSSIFYING SARCOMA. 301 

mass uf light cancellous bone, about five inches in its 
chief diameter, and very slightly connected with the 
remaining bones of the face. At its lowest part it pre- 
serves somewhat of the form of the alveolar border of the 
upper jaw, and the incisor, canine, and bicuspid teeth are 
implanted in it. 

The patient was a woman, aged thirty, who died in the 
Westminster Hospital from hfcniorrhage; consequent uj)on 
the extraction of some teeth from the tumour in question, 
which is described as " fleshy," and of a florid red colour 
where it appeared in the mouth. The tumour had been 
growing five years. No details are furnished by Mr. How- 
ship as to the post-mortem examination of this patient, but 
the skull shows a very important feature — a circular portion 
of the frontal bone just above the right temple, which is 
thin and perforated by several small apertures, apparently in 
consequence of the growth of a tumour from the dura mater. 
There is thus evidence of a secondary growth within the 
skull ; and taking the history of the case together with the 
specimen, I am inclined to regard this as an example of 
sarcomatous disease. 

0. Weber quotes from Titman (1757') a remarkable case 
which he considers of the same kind. The tumour was in 
a youth of fonrLeen, and had been growing for four years, 
and finally occupied the entire face. It had displaced the 
eye, the nose, and the lower jaw, and projected in such a 
way into the mouth and fauces that the patient died of 
inanition. The mass weighed six pounds, and on being cut 
through was quite white, and very hard, and had radiating 
masses of bone interspersed through its substance. 



302 



CHAPTEli XX. 

MALIGNA^"! TUMOUKS OF THE VTFYAl JAW. 

JRonnd-celled Sarcoma and Upithclioma. 

Round-celled Sarcoma or iiiediiUary sarcoma is of fref[uent 
occurrence in the upper jaw, and from its vascularity and 
rapidity of growth it has often been mistaken for medullary 
cancer, which in its clinical history it closely resembles. In 
the majority of cases the disease begins in the antrum, for 
the protruding masses, which are found in the nose or mouth, 
are but secondary to a formation within that cavity. One of 
Mr. Liston's cases is conclusive on the point, the preparation 
being preserved in the College of Surgeons (1059), with the 
following description : — " The greater part of a left superior 
maxillary bone, with a tumour formed in the antrum, re- 
moved by operation. The tumour measures about two 
inches in its greatest diameter, and projects forwards over 
the right canine and bicuspid teeth. Tt is pale, soft, and 
homogeneous, and the surface of its section is like that of 
brain. At the upper part its tissue is broken, and was 
mixed with blood : in its recent state it was more brain- 
like. The patient, William Thomson, was sixteen years 
old. The disease had been observed for two years. He 
had often suffered pain in the situation of the first molar 
tooth, which had been in a decayed state for a considerable 
time previous to his discovering any swelling of the cheek. 
During the two months preceding the operation the tumour 
had grown rapidly. Three years and a half after its re- 
moval the patient was in good health," — See Liston's paper, 
Medico- Chirurgical Transactions, vol. xx. In this case, 



ROUND-CELLED SARCOMA. 303 

which was fortunately submitted to operation- at a very early 
period, the disease was still confined to the antrum, and tlie 
removal of the jaw therefore included the whole of it. 
Unfortunately, in too many cases the disease is much more 
advanced before it is brought under the notice of the 
surgeon, when therefore the possibility of complete extirpa- 
tion is much reduced. 

Medullary sarcoma of the jaw closely resembles the same 
disease in other parts of the body, rapidity of growth, with 
softness, and a tendency to fungate on the part of the tumour 
itself, being the main characteristics. The direction which 
the disease takes, and the eftects therefore which it produces, 
will vary in different examples. Frequently it forms a 
considerable projection on the cheek, causing epiphora from 
closure of the nasal duct, and n2dema of the lower eyelid ; 
and in the later stages enlargement of the facial veins, 
without the least invasion of the hard palate, and with but 
slight niterference with tlie nostril. The specimen of 
medullary sarcoma represented in fig. 139 (College of Sur- 

Fia. 139. 




geons' Museum, 2243), illustrates the point, a large tumour 
being developed externally. The patient was a man, aged 
forty- four, who came under the care of Mr. Craven, of Hull, 
in 1863, with a large rounded tumour of the right clieek, of 



304 MALIGNANT TUMOURS OF UPPER JAW. 

the size of an orange, extending from the external process of 
the frontal bone and zygoma above, to the angle of the 
mouth below (almost completely closing the right eye), and 
from the side of the nose to the ramus of the lower jaw. 
The colour of the integument was natural, except at the 
upper part below the eye, where it presented a rather livid 
appearance, and several veins, not of large size. It was 
very firm to the touch, but elastic, especially at the outer 
part. Pressure and handling caused little or no pain. The 
interior of the mouth on the right side, from the alveolar 
process (which was concealed by the growth or embraced in 
it) to the inside of the distended cheek, presented a large 
excavated sore of a greyish sloughy aspect and foetid odour. 
This part of the tumour was softer to the touch than that 
which showed itself externally. It did not encroach on the 
palate, which was of the natural width. There were no 
enlarged glands beneath the jaw. The patient seemed a 
pretty healthy man. The tumour had been growing seven- 
teen weeks, Mr. Craven excised the tumour^ and the patient 
made a good recovery, but died fifteen months afterwards 
from a recurrence of the disease. The tumour (fig. 139) 
was rounded and lobed, especially that part which occupied 
the pterygo-maxillary fossa, and was firm on section. The 
cut surface was smooth, becoming slightly granular after 
prolonged exposure. To the naked eye the tumour had the 
appearance of a malignant growth. Under the microscope, 
the juice scraped off the cut surface showed no fibrous 
element, but simply a mass of apparently broken-up cells 
and granular matter. 

On the other hand, the disease may at an early period 
involve the alveolus and palate, or the nose, and it is these 
cases which are sometimes attributed to the presence of de- 
cayed teeth, or are mistaken for ordinary nasal polypi. Of 
this, a preparation (College of Surgeons' Museum, 2248), 
which is shown in fig. 140, and was also from a patient of 
Mr. Craven (to whom I was indebted for both valuable 
preparations), is an instance. Here the disease showed itself 
first in the gums, where it formed a fungating mass, and 



ROUND-CELLED SARCOMA. 



305 



soon obstructed the nostril. This last symptom was due to 
a fungus, almost pajDillaiy in appearance, which springs 
from the nasal surface of the tumour. Mr. Craven removed 



Fig. 140. 




the tumour in ]\Iarch, 1866, but within a year the disease 
returned and proved fatal. 

The disease may extend across the median line, and 
involve portions of both maxillae, especially the palatine 
plates. This is not necessarily a bar to operative inter- 
ference, provided other circumstances are favourable, but 
when the disease exhibits the appearance shown in fig. 141, 
the case is obviously one beyond the aid of surgery. The 
patient, aged twenty-four, was sent to me in January, 1868, 
by Mr. Harding, to whom he had applied for the extraction 
of some teeth, thinking to obtain relief thereby. Four and 
a half years before he had got a blow on the face from a 
cocoa-nut^ which broke the left canine tooth, and a year 
before I saw him, the left side of the face swelled up, but 
subsided again. In August, 1867, he first noticed a growth 
below the left eye, which rapidly increased, but even before 
this the interior of the mouth was tender, and felt swollen 
and soft to the touch. He had good advice in the 

X 



306 MALIGNANT TUMOURS OF UPPER JAW. 

country, and subsequently was in a London hospital, but 
operative interference was declined by the surgeon under 
whose care he was. When I saw him, some months later, 
there was a large soft tumour of the left upper jaw, and a 
smaller one on the right side, which had appeared about 
four weeks before. The nose was considerably projected by 
these, the left nostril being completely blocked and the right 
slightly so. The alveolus was very prominent, so that the 

Fig. 141. 



incisor teeth sloped backwards, and there were soft masses 
of disease on each side of the palate. Within a week or 
ten days of my seeing the patient the lymphatic glands in 
the neck had become enlarged, particularly on the right 
side, where a considerable tumour existed. This melancholy 
case was obviously totally untitted for operation at the time 
I saw it, whatever might have been its prospects at an earlier 
date. I could therefore hold out no hope of alleviation to 
the unfortunate patient, who returned to the country. 

Round-celled sarcoma occasionally involves both upper 
and lower jaws, beginning, I believe, mostly in the upper 
and extending to the lower. Fig. 142 shows a good instance 



ROUND-CELLED SARCOMA. 



307 



of this in a man who was under my care in 1877, with an 
enormous swelling of the left side of the face. I ventured, 
under chloroform, to introduce my finger into the mouth to 
explore the extent of the growth, but I found it so exten- 
sively attached to both upper and lower jaws that removal 
was clearly impossible. The examination gave rise to 

Fig. 142. 




sharp haemorrhage, due to the great vascularity of the growtli 
and this was checked with some difficulty with the per- 
sulphate of iron. 

I met witli the same implication of the lower jaw, though 
to a lesser extent, in a lady, from whom I removed the upper 
jaw in consultation with Dr. Csesar. In this case the coronoid 
process was involved and was removed with bone-forceps, 
but recurrence of the disease took place and the patient did 
not survive the operation four months. 

Epithelioma occurs in the upper jaw in two forms, the 
squamous and columnar ; and the former, which always 
begins in the gum or palate, has already been described 

X 2 



308 MALIGNANT TUMOURS OF UPPER JAW. 

(p. 257) ill connection with the autruin. Columnar epithe- 
lioma always begins in the antrum, which it often fills, and 
then secondarily involves the palate ; or it may attack the 
outer wall only of the antrum, and then protrude on the 
face. Occurring usually in patients over forty years of age, 
the disease begins very insidiously, the patient complaining, 
perhaps, of neuralgia or of uneasiness in the face, but of little 
more. When the antrum has become distended, the epithe- 
lioma is apt to involve the palate by absorption and eventual 
f ungatiouj and then protrude into the nostril and orbits. In 
the Museum of the College of Surgeons is a preparation 
(2235) of the right superior maxilla, with a soft white 
tumour filling the antrum and protruding into the nose and 
orbit, which I removed from a gentleman aged fifty-one, who 
five years before the operation, noticed " lumps in the hard 
palate," which were lanced, but never healed, though appear- 
ing to diminish in size. About four years later his right 
nostril became blocked, and there was protrusion of the eye. 
I removed the jaw very freely, but recurrence took place at 
the back of the orbit, and it became necessary to remove the 
eyeball in order to clear out the growth effectually, but even 
now it is not certain that a cure has been effected. 

The morbid growth in this case is unattached to the wall 
of the antrum, except behind, where it extends into the 
substance of the gums and palate. Mr. Eve's microscopic 
examination shows it to consist of closely j^acked and very 
tortuous columns of small round epithelium ; a few of them 
had a lumen, around whicli the cells were arranged in a 
regular manner, as in tubular glands. The stroma was com- 
posed of sarcomatous tissue. This case is one of unusual 
duration for an example of pure epithelioma, and the fact 
tliat the tumour is a mixture of epithelioma and sarcoma 
j)robably gives the clue to it, although the subsequent history 
is distinctly that of epithelioma. 

The more usual rapidity of growth of epithelioma of the 
upper jaw is well illustrated by a case I attended witli Mr. 
Sams, of Blacklieath, in the latter part of 1871. A lady 
aged fifty-two, had noticed a small growth in the gum of the 



EPITHELIOMA OF UPPER JAW. 309 

left upper jaw, which gradually overlapped the hard palate. 
This was removed by another surgeon in May, 1871, but the 
growth reappeared almost immediately. In November I 
found a fungus-looking mass involving the greater part of 
the left half of the liard palate, the bone of which was 
absorbed, and bulging up beneath the cheek. I removed the 
left half of the hard palate, with the whole of the growth, on 
November 24. In ten days the growth reappeared on the 
apparently healthy section of the hard palate and also in 
the cheek. A fortnight after the first operation I therefore 
again operated very freely, applying, as on the former 
occasion, a strong solution of the chloride of zinc to the 
entire wound. Again, within ten days, the disease reap- 
peared and rapidly filled up the cavity left by the operation, 
blocking the nostril and mouth, and eventually suffocating 
the patient in her sleep, on December 29. 

Even when the disease is far advanced, however, so that 
the tissues of the face and mouth are much involved, it is 
sometimes possible for the surgeon to give relief, if not per- 
manent cure, by completely excising the morbid structures. 

A case intermediate between the two foregoing in rapidity, 
and illustrating the advantage of operating in cases of epi- 
thelioma where a cure cannot be hoped for, was under my 
care during 1882-3. A lady, aged fifty-two, was sent to me 
in Marcli, 1882, by Sir Spencer Wells, with the following 
history: — A month before Christmas, 1881, she had noticed 
a swelling of the left cheek, and when I saw her had a 
unifonnly elastic swelling involving the left upper jaw, and 
spreading up the margin of the left orbit. The skin was 
tense and reddened, but not involved apparently, and the 
palate was healthy. I recommended removal, with the view 
of prolonging life, and in this view Mr. Erichsen coincided, 
but two eminent surgeons had given a contrary opinion. 

On March 24 I turned back a flap of the cheek, and found 
the tumour well covered with fascia and the skin healthy. 
I oj)ened the temporal fascia, so as to isolate the growth 
behind, and divided the zygoma afterwards, clearing the 
malar bone, and sawing the external angular process of the 



310 MA.LIGNANT TUMOUES OF UPPER JAW. 

frontal bone. Tlie palate was then sawn through, and the 
jaw readily removed. The remains of the hard palate were 
removed with bone-forceps quite up to the pterygoid process, 
which was healthy, and the parts were freely cauterized to 
make doubly sure. The patient made a good recovery, and 
left town much relieved on April 19. 

In September I saw her again, when there was an epi- 
theliomatous fungus at the outer angle of the wound 
measuring 1^ inclies across. No glands were enlarged, and 
the patient's health continued good. On September 28, I 
removed the growth and surrounding skin freely with 
Paquelin's cautery, and applied chloride of zinc paste. The 
mouth and cavity left by removal of the upper jaw were 
quite healthy, but the mouth could not be opened freely 
because the surface of the lower jaw had become involved 
by the disease in the cheek. On October 10 a recurrence 
of disease at the bottom of tlie otherwise healthy wound was 
noticed, and the caustic paste was re-applied. 

In November the patient returned with one small spot of 
epithelioma at the bottom of the wound, involving the 
mucous membrane of the mouth. This was thoroughly 
destroyed ^vith caustic paste, and the parts were quite sound 
when the patient went home. In February, 1883, there 
was a fresh recurrence in the cheek, but the patient was too 
weak to bear treatment, and she died in April, having sur- 
vived the first operation more than a year in comparative 
comfort, and with no formidable external tumour. 

The preparation from this case (College of Surgeons' 
Museum, 2246) shows a growth springing from the mucous 
membrane of the antrum, which in places is ragged and has 
a papillary appearance. Mr. Eve reported that under the 
microscope the mucous membrane of the antrum was ob- 
served to be exceedingly thickened by an overgi'owth of 
epithelium, for the most part of an elongated form. 

This condition corresponds very closely to that of another 
upper jaw removed by me in 1866, and now in the Museum 
of the College of Surgeons (2247 A.), which in former 
editions of this work I described as an example of " fibroid 



EPITHELIOMA OF UPPER JAW. 



311 



disease," but which is, I believe, really epitheliomatous. In 
September, 1866, Dr. "Whitmarsh, of Hounslow, brought to 
me a gentleman who, two years before, had perceived some 
growth in the right nostril, which gave no pain, but kept up 
a constant discharge, especially at night. In the early part 
of the year this had been removed in part by a surgeon, and 
since that the discharge had much increased. There was a 
fungous growth in the right nostril, and the whole right 
maxilla was swollen and discharged thin pus at one or two 
points near the eye. There was a fungous-looking growth 
in the molar region, and a probe passed by its side into the 
antrum. 

I removed the disease on September 23, clearing away 
the whole of the growth, which was very friable, and 
leaving the posterior wall of the antrum and the infra-orbital 
plate untouched. In the course of the operation I found a 
distinct polypoid growth filling the posterior nares, which I 
removed. The patient rallied well from the operation, but 
unfortunately got congestion of the lungs and died on the 
fifth day. 

The preparation is in the College of Surgeons' Museum 
(1053 B), and the appearance of a part of the disease is 
It will be seen that the interior of the 



shown in fig. 143. 



Fig. 143. 




antrum is covered with a remarkable papillary or villous 
growth, resembling some forms of cauliflower excrescence. A 
quantity of broken-down loose fibroid tissue lies at the bottom 
of the bottle of the preparation, and a portion of it, with 
the adjacent mucous membrane, is given in the sketch ; the 



312 MALIGNANT TUMOURS OF UPPER JAW. 

other portion bciiiig the polypoid growth extracted from the 
posterior nares. Mr. Bruce favoured me with the follow- 
ing report upon the specimen : — 

" It appears to consist of a tine soft fibrous stroma, in 
which very numerous nuclear bodies and a few elongated 
fibre cells are distributed. Its structure resembles that of 
the upper strata of a mucous membrane, from \vhicli it is 
probably an outgrowth." 

I have at present under my care a very interesting case 
of epithelioma, beginning in the outer plate of the upper jaw 
in an otherwise healthy man, aged fifty-three, who in October, 
1882, came into University College Hospital with a swelling 
of the right cheek about 1^ inches broad, extending from 
the nose to the zygoma, and clearly connected with the 
superior maxilla. The mouth and nostril were in no way 
involved, and I therefore deterjnined to remove only the 
part of the maxilla affected — viz., its anterior surface. This 
I did by reflecting the skin and prolonging the infra-orbital 
incision to the malar bone, wdiich I sawed through. Then 
dividing the nasal process, I was able to break away the 
anterior wall of the antrum with the tumour, leaving the 
palate untouched. The tumour was 3 inches long and 2 
broad, and grew from the outer wall of tlie antrum, which it 
had not penetrated. The substance of the growth was of a 
faint pinkish colour, very firm, and not lobulated, and micro- 
scopically was thought to be a myxo-sarcoma (?), 

The patient made a rapid recovery and remained in good 
health for three months, when he noticed a fulness above 
the malar bone, which increased until his re-admission at the 
end of March. It was then found that the upper margin of 
the malar bone, the zygomatic arch, and the lower part of the 
temporal fossa were all obscured by a firm growth, the skin 
over it being slightly reddened and fairly movable. On 
March 29, 1883, I exposed the new growth and isolated the 
bone to which it was attached, by dividing the zygoma far 
back and the external angle of the frontal bone ; but on 
breaking the malar bone away with the tumour I found that 
the antrum was now filled with new growth, and therefore 



EPITHELIOMA OF UPPER JAW. 313 

removed the superior maxilke in the usual way, afterwards 
applying caustic paste to the exposed surface. The soft 
material now filling tlie antrum was clearly epitheliomatous. 
The patient again made a good recovery, but in June it 
became necessary to remove the eyeball,- \vhich had suppu- 
rated. In November the patient again presented himself 
with a perfectly healthy cicatrix in the mouth and wearing 
an artificial palate, but with the lower and part of the 
upper eyelids infiltrated with epithelioma which had sprung 
up in the neighbourhood of the old cicatrix below the eye. 
This I removed freely wdth Paquelin's cautery, and subse- 
quently applied caustic paste freely, the disease being 
entirely outside the cavity of the mouth. 

In some cases of epithelioma it is impossible at the time 
of the operation to remove the whole of the disease. Of 
this an example will be found in the Appendix (Case XI.), 
where the tissues of the orbit were found to be extensively 
involved. This case also illustrates the fatal consequences 
to which elderly and feeble patients seem specially liable 
after operations on the mouth — viz., to a low form of broncho- 
pneumonia, by. some considered to be septic in its nature, 
which is rapidly fatal. The careful record of the post- 
mortem examination of this patient by Mr. Barker gives a 
typical example of the pathology of this disorder. 



314 



CHAPTEE XXI. 

DIAGNOSIS AND TREATMENT OF TUMOURS OF THE UPPER JAW. 

, The diagnosis of tumours of the upper jaw is by no means 
simple. Even the distinction between fluid tumours due 
to cystic enlargement of the jaw and solid growths, is, as 
has already been pointed out, not always easy; and it is still 
more difficult, and in some cases impossible, to decide as to 
the malignancy or otherwise of a tumour previous to its 
extirpation. 

The fibrous, cartilaginous, and osseous tumours are all of 
slow growth, painless, and more or less hard to the touch. 
They do not affect the general health, nor do they show any 
tendency to involve the surrounding tissues o''; the skin, 
except by mechanical interference. The fibro-sarcomatous 
and myeloid timiours are more rapid in their growth, and 
softer than those abeady mentioned ; both are more vascular 
in appearance at points where they are covered only by 
mucous membrane. They occasionally ulcerate, but do not 
fuugate, and may, under these circumstances, discharge 
blood in considerable quantities. The medullary-sarcoma- 
tous and epithehomatous tumours are the most rapid in their 
growth, and their tendency to involve surrounding structures 
is early manifested. Its softness and tendency to fungate 
are the chief characteristics of epithelioma, but these must 
not be relied on too implicitly. This last variety is ordinarily 
more painful than the others, the patient frequently com- 
plaining of neuralgic or gnawing pains in the head and face. 

In examining a case of tumour of the upper jaw, a careful 
inspection should be made of the face, mouth, and nares. 
The consistency of the projection beneath the cheek should 



OPERATIONS ON THE UPPER JAW. 315 

be tested with the finger both outside and inside the cheek 
itself. The condition of the hard and soft palate should be 
particularly investigated, and the finger should be carried 
behind the soft palate, if there is any suspicion that the 
tumour extends towards the posterior nares. The removal 
of a tooth may assist in the diagnosis^ either by evacuating 
fluid, or by bringing away with it a small portion of growth 
which may be submitted to microscopic examination. The 
condition of the nostril will require especial examination, 
particularly in those cases where the disease shows itself at 
an early period in that cavity, and doubt arises as to its 
nature. The careful introduction of a probe whilst a good 
light is thrown into the nostril, will enable the surgeon to 
decide whether the tumour is merely a polypus springing 
from the turbinate bones, or whether it is a portion of an 
antral tumour showing itself in the nostril, or possibly some 
growth springing from the base of the skull and simulating 
maxillary disease. 

Prognosis. — But little can be hoped from medicine in the 
treatment of tumours of the upper jaw. The application of 
iodine has been said by Mr. Stanley to have affected the 
removal of a small enchondroma, and no harm will be done 
by resorting to such measures and to the internal adminis- 
tration of absorbent medicines, for a short time whilst the 
progress of the disease is watched, provided no chemical 
agent be applied to the growth itself, by which it might be 
irritated or caused to inflame. Eemoval by surgical opera- 
tion is, however, the only effectual means of treatment, and 
the sooner an operation is undertaken the better in all cases, 
since even a benign tumour may, by its size or by its attach- 
ments, put a patient's life in danger if allowed to grow 
unchecked for a series of years. In malignant disease the 
only hope for the patient is early and complete removal, 
whilst the disease is confined to the bone and before the 
surrounding structures have become affected. 

Ope7xUions on the Uj^^^e?' Jaiv. — From early times portions 
of the upper jaw, and particularly the alveolus, were occa- 
sionally removed on account of some disease, and with more 



316 OPEEATIONS ON THE UPPER JAW. 

or less permanent success. Mr. Butcher, who has labo- 
riously investigated the subject^ puts the earliest casein 1693, 
the operator being Akoluthus, a physician at Breslau. De- 
sault, Garengeot, Jourdaiu, and others in the last century 
removed growths from the jaw, gouging them out with 
chisels with partial and temporary success ; and Dupuytren 
especially advocated this mode of treatment in his " Le9ons 
Orales," and frequently practised it, removing in this manner 
the greater part of the upper jaw in 1824. Charles White, 
of Manchester, appears also to have successfully operated on 
a patient, from whom he removed, piecemeal, nearly the 
whole of the upper maxilla during the last century. 

The late ]\Ir. John Lizars, of Edinburgh, appears to have 
been the first to jjropose removal of the entire superior 
maxilla as a whole in 1826, when, in his " System of Ana- 
tomical Plates," he showed how, anatomically, it would be 
possible to remove the bone without injury to important 

Fig. U4. 




and vital parts, and recommended the previous deligation 
of the common carotid artery, with a view of preventing 
haemorrhage. Mr. Lizars did not have an opportunity of 
carrying his proposition into efi'ect until December, 1827, 
when, notwithstanding the ligature aiDplied to the carotid, 
the haemorrhage was so fearful as to necessitate a discon- 
tinuance of the operation {Lancet, 1829-30). M. G ensoul, 
of Lyons, had, however, forestalled Mr. Lizars quite inde- 
pendently and without being aware of his proposition, for 



OPERATIONS ON THE UPPER JAW. 



317 



in May, 1827, he removed the entire superior maxillary bone, 
with a part of the palate, from a boy of seventeen, on 
account of a larsie fibro-cartila£Tinous tumour. The incision 
employed by Grensoul (fig. 141) was a vertical one from the 
corner of the eye to the lip, joined midway at right angles 
by a transverse incision, which was again met by a small 
vertical incision ascending to the malar bone. By the em- 
ployment of the mallet and chisel the jaw, with the tumour, 
was dislodged and removed by the division of the palate. 
Although the carotid was not tied the haemorrhage was not 
very great, and the patient recovered. — [Lettre Ghirurgicale 
SUV quelques Maladies Graves cht Sinus Maxillaire, par A. 
Gensoul). 

Mr. Syme operated successfully in May, 1839 {Edinhurglo 
Medical and Surgical Journcd, 1829), and Mr. Lizars also 
o]3erated again in 1829, for a medullary tumour, which was 
completely removed with the exception of a small portion 
attached to tlie pterygoid processes. The patient had 



Fia. 145. 



Fig. 146. 




become quite convalescent, when she died suddenly on the 
nineteenth day {London Medical Gazette, vol. v. p. 92). 
His third and successful operation was in 1830 {Lancet, 
1829-30), and from that time removal of the upper jaw 
became an established operation in surgery. ]\Ir. T,izars 
used an incision across the cheek from the angle of the 



318 OPERATIONS ON THE UPPER JAW. 

mouth to the mahir bone (fig. 145), or when the tumour 
was very large, employed in addition an incision through 
the lip into the nostril, with a vertical cut at the malar 
hone (fig. 146). With the saw and bone-forceps the maxilla 
was separated from its attachments and removed. 

Lizars' example was followed by most of the leading 
surgeons of the day, but Mr, Liston requires especial notice, 
since he performed some of the earliest and most important 
operations of the kind, and in his essay, which has been 
frequently referred to (Medico- Chirurgical Transactions, 
vol. XX.), brought the subject and its relations to various 
forms of disease prominently under the notice of the pro- 
fession. Mr. Liston seems to have been strongly impressed 
with the notion that mahgnant disease of the jaw should 
not be interfered with, but this idea does not prevail among 
operating surgeons of the present day, for it is felt that it 

Fig. 147. 




is better to act upon the principle which guides operations 
upon cancerous growths in other parts of the body — to 



OPERATIONS ON THE UPPER JAW. 



319 



remove the growths, if feasible, in the hope of giving at 
least relief if not a permanent cure. 

Syme, Mott, Velpeau, Dieffenbach, O'Shaughnessy, Hey- 
felder, Fergusson, and Butcher may be mentioned as having 
performed the operation of excision of the superior maxilla 
repeatedly and successfully, and to Sir William Fergusson 
especially is due the proposal of modifications of the greatest 
moment in the method of procedure. Noticing the con- 
siderable deformity resulting from an incision from the 
angle of the mouth, which necessarily divides the facial 
nerve (fig. 147), and still more when a flap of skin has 
been reflected from the face by a double incision (fig. 56), 
Sir William Fergusson devised the plan of carrying the 

Fig. 148. 




incision solely through the median line of the lip into the 
nostril. By dissecting up the tissues of the nose and taking 
advantage of the stretching of the skin of the nostril, room 
may thus be obtained for the removal of any tumour not of 
large size ; but supposing this to be found impracticable, 



:320 



OPERATIONS ON THE UPPER JAW. 



it is still open to the operator to prolong the incision round 
the ala and up the side of the nose, and in the case of large 
tumours, to carry it in a curve below the orbit to the malar 
bone, as seen in fig. 148. The great advantages of these 
methods are that the facial nerve and facial artery are 
divided at points where their size is of no consequence, and 
consequently the loss of blood and the subsequent deformity 
are much diminished ; and also that the scars fall in such 
positions as to be hardly noticeable. 

The method of proceeding which I recommend when it is 
necessary to remove the entire npper jaw is as follows : — 



Fio. 149. 



Fxfi. LiO. 



The skin having been reflected in the manner described 
above, the incisor teeth of the side to be removed are ex- 
tracted and a narrow saw with a movable back passed into 



REMOVAL OF THE UPPER JAW. 321 

the nostril. With this the alveohis and hard palate are 
divided, and a small saw (fig. 149) is then applied to the 
malar bone in a line with the spheno -maxillary fissure, and 
to the nasal process of the superior maxilla, so as to notch 
both these points of bone, the division being completed 
with the bone-forceps. "With the " lion-forceps," devised 
by Sir William Fergusson for the purpose (fig. 150), the 
jaw can now be grasped and broken away from the pterygoid 
process and palate bone, any detaining point being severed 
with the bone-forceps. Lastly, when the bone is quite loose, 
the infra-orbital nerve is to be severed, and the soft palate 
divided at its attachment to the bone, so as to leave as 
much of it as possible uninjured, and any remaining portions 
of disease are then to be removed with the bone-forceps 
and gouge. Haemorrhage is to be arrested by ligatures and 
the application of the actual cautery to the deep tissues, and, 
finally, the lip and incision are to be brought together and 
carefully adjusted with hare-lip pins and interrupted sutures 
of fine wire or silk. 

When the disease is of less amount, and the orbital plate 
is not involved, this should be preserved by carrying a saw 
horizontally below it ; and if the palate is not involved, this 
may be advantageously kept intact by making a similar cut 
immediately above it. Under these circumstances the inci- 
sions through the skin need only be very limited, and the 
bone-forceps and gouge will be requisite to clear out all the 
disease from the antrum. 

Sir William Tergusson has, in his " Lectures on Anatomy 
and Surgery," strongly urged the pursuance of a less heroic 
plan than that which has hitherto been followed, in going 
completely beyond and not interfering with the diseased 
tissues. According to that eminent surgeon, it is better to 
cut into the disease and to clear it out by working from the 
centre to the circumference, so as not to remove healthy 
structures unnecessarily, and this may be accomplished by 
means of curved and angular bone-forceps of various sizes, 
and by the use of the gouge. Mr. Syme {British Medical 
Journal, Aug. 13, 1865) denounced this method as a return 

Y 



322 OPERATIONS ON THE UPPER JAW. 

to " the old system with its chisels and gouges ;" but the 
practice, as regards non-cancerous tumours at least, has 
recently received the strong support of Sir James Paget, who 
in a paper in the Mcdico-Chirurgical Transactions, vol. liv., 
has urged the propriety of enucleating simple tumours 
growing in the interior of bones, and among other cases 
gives one of a lad of nineteen, from whose antrum he suc- 
cessfully removed a large mass without injury to the palate 
or orbit. A similar instance, under my own care, is given 
at p. 267. The case^ is, however, different when the disease 
is of a malignant character, and, after some considerable 
experience, I am decidedly of opinion that the surgeon must 
go well beyond the boundaries of the tumour if he hopes to 
give the patient permanent relief. The practice of cutting 
into a malignant growth gives rise to considerable htemor- 
rhage, which renders it very difficult to be certain as to the 
removal of the entire disease. It is better, therefore, 1 
think, to cut into the healthy bone beyond, so as to be quite 
certain of removing the entire growth, though it is by 
no means necessary to remove large portions of healthy 
structure. 

In cases of epithelioma, wdiere even the whole of the 
diseased structures have been removed, I would strongly 
advise the application of the chloride of zinc paste, made 
with hydrochloric acid and opium, after the formula of the 
Middlesex Hospital. Applied on the end of a strip of lint 
to the doubtful part, the rest of the lint can be packed in 
and covered over with a pledget of cotton-wool, so as to 
prevent the escape of the chloride of zinc into the mouth ; 
and I have found it very advantageous to plug the posterior 
nostril on the af!'ected side from the front with another 
strip of lint, so as to obviate the escape of fluid into the 
throat. After three days the plugs are easily withdrawn 
from beneath the cheek, and free syringing will keep the 
parts sweet while the sloughs caused by the caustic are 
separating. For washing out the mouth there is nothing 
better than the syphon nasal-douche with a soft nipple. 

In cases of epithelioma in which the skin is involved, the 



LIGATURE OF THE CAROTID ARTERY. :^23 

portion so diseased must be sacrificed if a cure is to be 
hoped for. This may be effected with the knife or the 
actual cautery, and I may refer to a very successful example 
of this method of treatment by Mr. Lawson, recorded in the 
Clinical Society's Transactions, vol. vi. 

As a local antiseptic nothing is equal to powdered iodo- 
form, freely applied to the raw surfaces both of bone and soft 
parts. In this way the cavity left by removal of the upper 
jaw may be kept sweet for days after the operation, and the 
patient be spared the risks of purulent infection or septic 
bronchitis. 

It has been mentioned that in the earlier operations for 
removal of the upper jaw, it was customary to apply a liga- 
ture to the common or external carotid artery. Although 
this practice has now been quite abandoned, it has in a few 
cases been necessary to secure the main vessel after the ope- 
ration, on account of secondary haemorrhage. Thus Mr. 
Field, of Brighton, tied the common carotid two days after 
removal of the upper jaw, in 1858, and the patient recovered 
{Medical Times and Gazette, Aug. 28, 1858). In a patient 
of Mr. Holmes Coote, at St. Bartholomew's, in 1866, the 
house-surgeon, Mr. Orton, tied the vessel on the nineteenth 
day, but the patient sank {Lancet, Oct. 13, 1866). In his 
recent work on Cancer, Mr. 0. Pemberton mentions a case 
which occurred in 1848, when he was house-surgeon at tlie 
Birmingham General Hospital, which also proved fatal. 

As a rule, however, patients who have been submitted to 
removal of the upper jaw recover with wonderful rapidity. 
Of course the primary shock of such an operation is severe, 
but when this is once got over the convalescence is ordi- 
narily rapid. 

Piemoval of both uj)per jaws has occasionally been per- 
formed. A case in wliich Mr. Lane removed the greater 
part of both jaws has been referred to in this essay (p. 288), 
and the operation has been performed by Eogers, of New 
York (1824), Hey f elder (1844, and twice afterwards), Dief- 
fenbach, Maisonneuve, and others. Heyfelder made two 
incisions from the outer angles of the eyes to the corners of 

^y 2 



324 OPERATIONS ON THE UPPER JAW. 

the mouth, and reflected this quadrihiteral flap to the fore- 
head, taking the nose with it. He then passed a chain-saw 
through the spheno-maxillary fissure on each side, and thus 
separated the jaws and the malar bones. The junctions 
with the nasal bones and vomer were then divided with bone- 
forceps, and the soft palate separated from the margin of the 
hard. Lastly, powerful traction upon the bones was exerted, 
and the bones were displaced. Dieffenbach, Maisonneuve, 
and others, employed a median incision, beginning at the 
root of the nose and ending in the median line of the lip, so 
as to divide tlie skin of the face into two lateral flaps. This 
appears an unnecessary complication however, since division 
of tlie lip and free dissection of the nostrils would afford 
sufflcient room for the removal of the jaw in two halves. A 
paper on Total Double liesection of the Upper Jaws, by 
H. Brauu^ of Heidelberg, will be found in Langenbeck's 
Archiv, xix. 1876. 

In 1872, Mr. Dobson, of Bristol, removed both superior 
maxilla? of a woman, aged fifty-two, by dividing the lip in 
the middle line and carrying an incision up each side of the 
no«e {British Medical Journal, Oct. 11, 1873), and ]\Ir. 
Bellamy informs me that he has recently removed the greater 
part of both upper jaws by simply reflecting the lip with- 
out any external incision. 

Dr. Charles Brigham, of San Francisco, has reported in 
his " Surgical Cases with Illustrations" (1876), an instance 
of successful removal of the entire upper jaw for malignant 
disease, after performing tracheotomy and plugging the 
pharynx with sponge. In a case of such extensive disease 
the preliminary tracheotomy was, no doubt, admirable, but 
for ordinary cases of removal of tumours of the upper jaw the 
proceeding seems to me uncalled for, as I have never em- 
ployed it, and have only seen it employed on one occasion. 
Professor Trendelenburg's proposal to perform a preliminary 
tracheotomy, and to plug the trachea by a special expanding 
tampon in all serious oj)erations about the mouth, was made 
in 1871, and will be found described at length in i\\Q Medical 
Times and Gazette for IMay, 1872. I lia^e employed the 



TREATMENT OF H^MORBHAGE. 325 

tampon once in operating on the tonguC; and once (unneces- 
sarily as it turned out) in operating on the palate ; 
but the objection to it is, that the pressure exerted on the 
trachea is apt to produce great embarrassment of breathing 
and cough. Plugging the pharynx with a sponge, to which 
a string is attached, is a far preferable plan, and I strongly 
advise that the preliminary tracheotomy, if considered neces- 
sary, should be done a couple of days beforehand, so that 
the patient's windpipe may have become accustomed to the 
presence of the tube. A much more satisfactory plan, if it 
prove generally feasible, is that practised by Dr. McEwen, 
of Glasgow {British Medical Journal, July 24, 1880) — 
viz., to introduce a tracheal tube through the mouth for 
the administration of chloroform during operations in the 
mouth, the pharynx being plugged around the tube with 
sponge. 

The fear of haemorrhage in cases of removal of the upper 
jaw is exaggerated, 1 think, for there is no large vessel 
implicated until the last stage of the proceeding, when the 
bone is forcibly displaced ; and then, if the operator is rapid 
in his movements and his assistants are prompt, pressure can 
be made with a sponge thrust into the cavity quite sufficient 
to prevent blood flowing into the fauces, until the operator is 
ready to pick up the bleeding vessel. I always provide 
myself with a small sponge, which I thrust into the 
posterior nostril of the affected side the moment the 
larger sponge held by an assistant is removed. This pre- 
vents any blood flowing into the pharynx, and allows of de- 
liberate examination and the arrest of bleeding by the ligature 
or the cautery. 

As regards the position of the patient I always have him 
recumbent, with the head fairly raised on pillows, and invari- 
ably employ chloroform as the anaesthetic, both because it is 
impossible to keep a patient under the influence of ether 
when air must necessarily be admitted very freely by the 
manipulations of the surgeon, and because of the danger of 
ignition of the vapour of ether in the patient's mouth by 
the application of the actual cautery. 



326 OPERATIONS ON THE UrPER JAW. 

Since it is unadvisable that a patieut about to have a jaw 
removed should take food for four liours beforehand, lest 
sickness should be induced by chloroform or swallowing 
blood, I am inclined to recommend a practice, which I 
have lately followed, on the suggestion of Dr. Prince, of 
Jacksonville, Illinois {St. Louis Medical and Surgical Journcd, 
Feb., 1883) — viz., to inject into the colon, shortly before a 
severe operation, a quantity of hot brandy and water, suited 
to the age and requirements of the patient. The ingenious 
rectal obturator devised by Dr. Prince, or a very similar 
invention of Mr. Edward Lund {Lancet, April 7, 1883), is by 
no means necessary, for the fluid, if injected with a fairly 
long enema tube while the patient is recumbent in bed, has 
little tendency to escape. 



327 



CHAPTEE XXII. 



NOX-MALIGNAXT TUMOURS OF THE LOWER JAW. 

Fihroma, Enchondroma, Osteoma. 

Fibrous Tumour is the commonest form of growth in the 
lower jaw, and, as pointed out by Paget, this may take the 
endosteal or periostecd form. The formation of fibrous 

Fig. 151. 




tumours between the pLates of the lower jaw has been 
already referred to under the head of Inflammation (p. 98), 
and originates, I believe, in the majority of cases in some 



328 NON-MALIGNANT TUMOURS OF LOWER JAW. 

inflammatoiy deposit due to the irritation of decayed teeth. 
By the slow growth of the tumour the jaw is expanded, the 
outer plate yielding more readily than the inner, as is well 
seen in a preparation in University College Museum (fig. 151), 
which also shows a curious transportation of the wisdom 
tooth close up to the condyle of the jaw by the growth of 
the tumour, being probably connected with it in some way. 
In the College of Surgeons' Museum (2219) is a good 
specimen of endosteal fibrous tumour, which Sir Spencer 
Wells removed with the jaw from the symphysis to the 
angle, in a woman aged twenty-seven, whose condition at 
the time of the operation is represented in fig. 152, from a 
j)hotograph by the late Dr. Wright. The tumour occupied 

Fig. 152. 




the left side of the lower jaw, and had existed for four 
years, being connected with decayed teeth, one of which on 
being extracted shortly before the operation brought a small 
portion of the tumour away with it. Fig. 153, also by Dr. 
Wright, shows the tumour in the recent state (see Patholo- 
f/ical Society's Transactions, vol. xii.}. 

It may, I think, be doubted whether a milder treatment 
than that of removal of the whole thickness of the bone 
containing tumours of this description might not sometimes 



FIBROMA OF LOWER JAW. 



329 



be adopted with advantage. A specimen in the Museum 
of King's College (132—19), which is represented in fig. 154, 
admirably illustrates this view. It is a fibrous tumour re- 



FiG. 153. 




moved, when I happened to be present, by Sir William Fer- 
gusson, from a woman who had undergone two previous 
operations. Having sawn the jaw partly through on each 



Fig. 154. 




side of the tumour, the operator applied the bone-forceps 
to complete one of the sections, when the outer plate of the 
jaw with the greater part of the tumour came away, leaving 



330 NON-MALIGNANT TUMOURS OF LOWER JAW. 

only a small portion of it adhering to the inner plate. Owing 
to the jaw being already divided, it was considered better to 
coni})lete the operation as originally intended, and the 
patient made a good recovery. The preparation referred to 
illustrates also the connection of the teeth with fibrous 
tumours, a diseased molar tooth being implanted in the 
upper part of the tumour. 

The advantage of not breaking the line of the lower jaw 
has been already insisted upon in connection with epulis, and 
the same advantage would be gained by preserving, where 
possible, the inner plate of the jaw in cases of tumour. 

I have recently had a patient under my care who had a 
fibrous tumour of the size of a large marble, in the lower jaw, 
in the position of the right molar tooth. This was imbedded 
between the plates of the jaw, and had considerably ex- 
panded the bone. I succeeded in nmioving the growth 
from within the mouth by means of the large forceps shown 
in fig. 123, and the patient made a good recovery. Sir J. 
Paget, in the paper already referred to (p. 322), gives two 
cases in which he successfully removed tumours from within 
the lower jaw, one, a bony tumour, and the otlier, and more 
remarkable one, a cartilaginous growth which was removed 
by the gouge, and did not reappear. 

A specimen of fibrous tumour, presented to the College of 
Surgeons' Museum (2217) by Mr. Bryant, illustrates the 
same point. The section shows that the fibrous tumour 
is free towards the alveolar border of the jaw, but enclosed 
in the bone below. It is separated at all parts from the 
osseous tissue by a fibrous layer forming a kind of capsule, 
and might therefore probably have been enucleated from its 
cavity without any great difficulty. 

A specimen, now in the Museum of the College of Sur- 
geons (2220), and for which I was indebted to Mr. Buxton 
Shillito, shows the satisfactory result of the treatment here 
recommended. The case is reported, with drawings, in the 
Pathological Transactions, vol. xvi., and the tumour was 
removed by Mr. Shillito from near the angle of the lower 
jaw of a young woman aged twenty-six, where it had been 



FIBROMA OF LOWER JAW. 331 

growing fifteen months, being of the size of a walnut. It 
was removed by reflecting a flap of skin from its surface, 
cutting through the thin shell of bone, and enucleation. 
It left a perfectly smooth cavity into which the fang of the 
second molar tooth projected, which doubtless was the 
original cause of the mischief. The tumour was gritty on 
section, and furnished an example of calcification, to which 
change fibromata of the lower jaw are liable no less than 
those of the upper jaw. 

■ Though of slow growth under ordinary circumstances, a 
fibrous tumour of the jaw, if irritated by the injudicious 
application of useless remedies with the view of producing 
absorption of the growth, may assume enormous proportions, 
and destroy life by the irritation and continuous discharge 
it gives rise to. A preparation in King's College Museum, 
shows a fibrous tumour of lai'ge size, involving nearly the 

Fig. 155. 




^ II 



whole of the left side of llie lower jaw. Its interior is 
hollowed out into a large cavity with sloughing walls, and 
there is a large aperture communicating with it surrounded 
by healthy skin. The patient's portrait, taken about six 
weeks before her death, is seen in fig. 155. The case 
was evidently one of ordinary fibrous tumour depending 
originally upon diseased teeth, which, by dint of incisions 



332 NON-MALIGNANT TUMOUES OF LOWER JAW. 

and injections of iodine into the growth, followed by a seton 
introduced tlirougli the skin, was brought into such a con- 
dition that, upon the receipt of a blow, it rapidly brought 
the patient to her deathbed. 

A remarkable and unique feature in connection with 
the case of large fibrous tumour above referred to, is seen 
in fig. 156, which shows the front of the base of the 
skull of the patient. The long-continued pressure of the 
tumour of the lower jaw has given rise to a remarkable con- 
traction of the hard palate and alveolus, the teeth being 

Fig. 156. 




crushed together so as to overlap one another, and at the 
same time an expansion of the malar bone and zygoma has 
ensued, which is accurately shown in the drawing. 

A large tumour of the same kind, weighing eighteen 
ounces, which has encroached upon tlie condyle and coro- 
noid process, and projected into the mouth as well as on the 
surface, is preserved in University College Museum (652), 
and was removed by Mr. Listen in 1846 ; and a similar 
growth, successfully removed by Prof. William Beaumont, of 
Toronto, from a boy of seven, which is considerably infiltrated 
with calcareous matter, is in the Museum of the College of 



FIBROMA OF LOWER JAW. 333 

Surgeons (2218), and was originally considered to be carti- 
laginous {Mcdico-CMrurgical Transactions, vol. xxxiii.). It 
weighed eight ounces avoirdupois, with a long diameter 
of 3-j-V inches, and a short diameter of 2-^ inches, and 
involved the whole of the left side of the bone. 

The patient, a child aged seven years, was admitted into 
the Toronto Hospital, Sept. 17, 1819. The tumour^ on 
his admission, extended upwards to the zygoma and malar 
bone, almost covering the temporo-maxillary articulation ; 
it reached downwards to fully an inch below the angle of 
the jaw, extending inwards into the mouth as far as the 
mesial plane ; backwards beyond the ramus of the jaw, and 
forwards to the posterior bicupsid. It pushed the tongue 
quite to the right of the mesial plane, concealed the velum, 
and almost completely filled the isthmus faucium ; the 
molar teeth of the upper jaw were deeply imbedded in the 
tumour, which kept the mouth at all times open, with a 
constant dribbling of saliva, the upper and lower incisors 
not meeting by fully half an inch. Tlie tumour had been 
first observed three months before. On Sept. 25, 1849, 
Professor Beaumont performed the operation for its removal, 
commencing by making a curved incision (the concavity up- 
wards), extending from the lobule of the ear to the angle of 
the mouth, dissecting ofT the integuments from the tumour. 
The tumour was firmly w^edged in under the malar bone ; 
the outer wall of the jaw was cut vertically through with a 
small straight saw ; the section was then at one stroke com- 
pleted with a strong bone-forceps ; the condyle was disarti- 
culated by being firmly grasped in a forceps, the joint being 
opened by dividing the external lateral ligament and cap- 
sule. The patient did very well ; a small salivary fistula was 
formed in the cheek, which eventually healed, and on Dec. 1, 
1849, the patient was quite well. The right half of 
the lower jaw was drawn a very little towards the left side, 
about an eighth of an inch ; the external cicatrix was a 
mere line. 

Fibrous tumour is most frequently developed in the side 
of the lower jaw, where the space between the plates is 



334 NON-MALIGNANT TUMOURS OP LOWER JAW. 

larger than elsewhere, and may occupy the dental canal, as 
in a case of j\Ir. Cock's, in which the dental nerve passed 
through the tumour, necessitating its removal in two parts 
(Guy's Hospital Museum, 1091, 25). Occasionally, however, 
fibrous tumour invades the symphysis, and here, owing to 
restricted amount of expansion of which the bone is capable, 
absorption of the anterior surface takes place at an early 
date, and the tumour projects, involving also the adjacent 
bone. A preparation in University College (655) shows the 
symphysis affected in this way, which was removed, with a 
portion of healthy bone on each side, by Mr. Listen. A 
section shows the structure very well, and at the lower part 
a small cyst has been developed. In connection with this 
subject, another preparation in the same museum (654) is 
deserving of notice, being a fibrous tumour, of the size of 
an orange, connected with the back of the sympliysis, and 
apparently, therefore, of the periosteal variety. 

The 'jj^^^^'^osteal variety of fibrous tumour is not distin- 
guishable from epulis except by its size. Like epulis it has 
spicula of bone springing from the jaw, permeating it for a 
short distance, and beyond them radiating lines may be seen 
in the fibrous tissue. Preparation 2221 in the Museum of 
the College of Surgeons, which accomj)anied this essay, and 
for which I was indebted to Mr. Lee, of the Salisbury 
Infirmary, illustrates this form of disease very well, the 
fibrous growth being closely connected with the periosteum 
of the front of the jaw. The disease may, however, almost 
completely [surround the jaw, as the preparation in St. 
Bartholomew's Hospital, drawn by Sir J. Paget in his 
" Surgical Pathology," 

Enchmidroma of the loM^er jaw is not common, but is 
found of two forms, the endosteal and periosteal, thus 
resembling fibroma. The disease generally occurs early in 
life, and makes slow but steady progress, the periosteal 
variety acquiring a very large size. A specimen in Guy's 
Hospital Museum (1019, 15, and 16) shows very well the 
relation of the endosteal variety to the bone, the growths 
occupying the space between the plates of the jaw, and the 



EXCHONDROMA OF LOWER JAW. 335 

teeth being imbedded in it. The specimen was removed by- 
Mr. Key from a woman aged twenty-nine, in whom it had 
been growing nine years, by sawing through the bone on 
each side of the tumour, 

A somewhat similar case is recorded by Sir Astley Cooper, 
in his " Essay on Exostosis," and is remarkable both for the 
sound pathological views and strictly conservative treatment 
he therein advocates. The patient was nineteen, and had 
had a growth in the side of the lower jaw for three years. 
Sir Astley exposed the tumour and gouged it away, exposing 
the dental nerve, and the patient made a good recovery. 
He remarks respecting it (p. 177), "With regard to the 
cause of the disease, it was evidently the irritation of the 
decayed tooth, the fangs of which projected into the carti- 
lage which was effused within the bony cavity, and which, 
instead of producing suppuration and ulceration, as it fre- 
quently does, kept up a degree of irritation that did not 
pass beyond the stage of adhesive inflammation, and a cartila- 
ginous deposit took place in the first instance, to which suc- 
ceeded an ossific effusion. As to the treatment of this 
disease, it consists in first seeking the source of the irrita- 
tion and removing it as soon as discovered, in order to pre- 
vent the further progress of the disease ; and, indeed, it may 
be probable that the removal of the source of irritation 
might sometimes, even when the disease has advanced to a 
considerable extent, succeed in producing a cure, and there- 
fore it is desirable to wait the event before any further opera- 
tion is undertaken. Should this, however, prove insuffi- 
cient, it will be necessary that the external shell of the bone 
be removed by means of a saw, and that the cartilage which 
it contains be dislodged by an elevator. If the integuments 
be carefully preserved, little deformity follows ; and thus, 
by a simple operation, destruction otherwise inevitable is 
prevented." Sir James Paget has recorded {Mcdico-Chirur- 
gical Transactions, 1871), a very similar case of cartila- 
ginous tumour in the lower jaw of a lady forty-five years 
old. It had been growing during two or three years, extended 
along the space between the first bicuspid and last molar 



336 NON-MALIGNANT TUMOURS OF LOWER JAW. 

teeth, was deep set in the jaw, expanding both the walls, 
and risins to almost the level of the molar teeth. He 
gouged it out, leaving the base of the jaw untouched, and 
not cutting any part of the cheek or lip. The patient had 
no return of the disease. 

The periosteal form of cnchondroma springs from the 
membrane covering any portion of the bone, but most fre- 
quently affects the body. It grows to an enormous size, 
and may cause death either by interfering with respiration, 
as in Sir Astley Cooper's case, or with deglutition, as in the 
case from which the preparation in the College of Surgeons 
was taken. 

Sir Astley^s patient was a girl of thirteen, in whom the 
tumour had made its appearance near the chin a year before 
she came under that surgeon's notice. The tumour increased 
until it measured five inches and a half from side to side, and 
four inches from the incisor teeth to its anterior projecting 
part. The circumference of the swelling was sixteen inches. 
The tongue was thrust back into the throat and to the right 
side, where it rested in a hollow between the angle of the jaw 
and the tumour. The epiglottis was bent down upon the 
rima glottidis so as to produce great difhculty in swallowing 
and breathing. The mental foramen was large enough to 
admit the little finger, and, owing to the elongation of the 
bone, was directed backwards. The preparation is preserved 
in the Museum of St. Thomas's Hospital (C. 201), and a 
section, which has been macerated, shows very well the ossific 
spicula from the surface of the bone projecting into the mass. 

In the Museum of the College of Surgeons is a still more 
remarkable specimen of the same disease (2215), the tumour 
measuring six inches in depth and about two feet in cir- 
cumference, and involving the whole of the lower jaw except 
the right ramus and angle. The patient, when thirty-two, 
had a small hard tumour on the right side of the lower jaw, 
just below the situation of the first molar tooth, which had 
decayed. This gradually increased, and ultimately proved 
fatal at the end of eight years, by inducing inability to 
swallow. 



ENCHONDROMA OF LOWER JAW. 337 

A specimen of enchondroma, weighing three and a-half 
pounds (German), removed by disarticulation by Chelius, 
is preserved in the Heidelberg Museum, and is figured by 
Otto Weber {op. cit.). 

A remarkable case of enchondroma of the lower jaw has 
been recorded by ]\Ir. Lawson {Pathological Society s Trans- 
actions xxxiv.), in which there were ten operations for as 
many recurrences during eighteen years. The report of a 
committee on some of the more recent recurrences goes to 
show, however, that these are more of the nature of spindle- 
celled sarcoma. 

The history of the case goes back to 1865, when the 
patient came under Sir William Fergusson's care on account 
of a large tumour, bulging below the jaw, and pushing into 
the mouth. He then removed the tumour, and at the same 
time took away five teeth from the lower maxilla, which 
appear to have been displaced by it. She made an excel- 
lent recovery, and for a time remained well, but the tumour 
recurred, and after two or three years was again removed by 
Sir William Fergusson. Unfortunately the patient had 
kept no account of the dates of the different operations she 
had undergone. She was only able to say that she was 
operated on twice between the years 1865 and 1872, 
and three times between 1872 and 1876 ; the last 
operation being in ISTovember, 1876, when Sir William ap- 
parently succeeded in getting away the whole of the 
gro^vth. 

On December 26, 1877, the patient, aged fifty-seven, a 
stout healthy-looking woman, was admitted into the Esta- 
blishment for Invalid Ladies, under Mr. Lawson, for 
the purpose of liaving the tumour again removed. Since 
the last operation the tumour had recurred, and, as she 
could not have the benefit of Sir William Fergusson's 
assistance, she had allowed the growth to remain until it 
had attained such dimensions that she was compelled to seek 
relief. 

On admission, the tumour presented the external appear- 
ance shown in the woodcut (fig. 157). It extended upwards 



338 NON-MALIGNANT TUMOURS OF LOWER JAW. 

to the level of the lower part of the ear, downwards in the 
neck to within two fingers'-breadth of the clavicle, and for- 
wards it was bulging close up to the nose. Looking within 
the mouth, the tumour was seen to occupy the greater por- 
tion of that cavity ; and it extended across the pharynx 
against which and the soft palate it pressed. The mouth 




could be closed, and she could take food without much diffi- 
culty, but her breathing was at times troublesome, and 
especially at night. 

On Jan. 7, 1878, Mr. Lawson removed the tumour with 
the portion of the lower jaw from the inner surface of which 
it grew (fig. 158), and the patient rapidly recovered. 

The tumour weighed close upon eighteen ounces. It was 
of a firm consistence, but easily cut with the knife. It was 
intimately connected with the periosteum on the inner side 
of the lower jaw, from wliich it apparently sprang. A por- 



ENCHONDROMA OF LOWER JAW. 339 

tion of the tumour was given, immediately after its removal, 
to Dr. Thin, who supplied the following report of his 
microscopical examination : — " I examined microscopically 
the portion of the tumour kindly given me by Mr. Lawson, 
and I believe the growth to be a chondrome of the class 

Fig. 158, 




named by Cornil and Eanvier cliondromcs hycdins lohules. It 
has the peculiarity that the cartilaginous tissue is of a very 
low type, so much so that the determination of the exact 
nature of the growth was a matter of some difficulty. Suc- 
cessful preparations, however, show that, except in the 
degree of development of the cartilaginous substance proper, 
the structure is identical with that described by pathologists 
as characteristic of these tumours." 

Dr. Coupland, the lecturer on Pathology at the Middlesex 
Hospital, examined the specimen of the growth prepared by 
Dr. Thin, and concurred in the report. 

Since the operation in 1878 there have been five opera- 
tions for extensive recurrence of the disease, and on each 
occasion similar masses of cartilage were removed. The 
recurrences have been in the neck and in the temporo- 
maxillary region, extending from the glenoid fossa of the 
temporal bone towards the base of the skull, and in the 

z 2 



340 NOX-MALICNANT TUMOURS OF LOWER JAW. 

cheek, between the mucous membrane and the external 
integument. At each operation the tumour was found to be 
composed of large isolated masses of cartilage, varying in 
size from that of the closed fist to a small nut, packed 
tightly together, and each portion enclosed in a distinct 
capsule, from which it could with little difficulty be enu- 
cleated. The masses of cartilage were of sufficient density 
to push before them in their growth all important structures 
w^ith which they were in contact. The patient is still 
living. 

Osteoma affiicts the lower jaw in two forms — the can- 
cellated and the ivory exostosis. The former is no doubt in 
many cases the result of ossification of enchondroma, as 
for instance, a specimen (C. 203) preserved in St. Thomas's 
Museum, which is of a spongy texture, and which is stated 
by Sir Astley Cooper to have been removed by Mr. Cline. 
Occasionally, however, a conversion of the whole thickness 
of bone into a lobulated mass of spongy bone is met wdth, 
of which an excellent example is preserved in St. George's 
Hospital Museum (II. 185). In this case the tumour, 
wdiicli was of the size of the fist, had been growing for five 
years, and had been on one occasion partially removed. Mr. 
Tatum successfully removed the entire portion of jaw affected. 
A case in wdiich a circumscribed bony tumour, measuring 
from two-thirds to three-fourths of an inch in diameter, and 
composed of hard, finely cancellous bone, was lodged in the 
interior of the angle of the jaw, is given by Sir J. Paget in 
the Medico- Chirurgical TraThsactioiis, vol. liv. 

Ivory exostosis appears to affect by preference the angle 
of the jaw. Of this a good specimen is preserved in St. 
George's Hospital (II. 191); and 0. Weber figures a section 
of a large ivory exostosis in the same region removed by 
Chelius. The best example of the kind, however, is in the 
College of Surgeons (2212), having been presented by Mr. 
J. F. South. The preparation (post-mortem) shows part of 
the right side of the lower jaw, with sections of a large bony 
tumour at its angle. The angle of the jaw rests in a deep 
groove on the middle of the upper surface of the tumour. 



OSSEOUS TUMOURS. 



341 



and in some situations their respective substances are con- 
tinuous. The tumour projects both below and on each side 
of the jaw, is of irregular shape, measures nearly three 
inches in its chief diameter, and is deeply nodulated. It is 
composed throughout of bone, uniform in texture, and as 
hard and heavy as ivory (fig, 159). 

In the Museum of St. Bartholomew's Hospital is the 
lower jaw of a young person (I. 3257) with two symmetrical 
eburnated exostoses springing from the inner surface of the 
alveolar portion of the bone on either side of the symphysis, 
corresponding in position to the bicuspid and first molar 



Fig. 159. 




teeth. The markings and slight lobulations of the bony 
outgrowths are more or less symmetrical. The rami of the 
jaw are unusually widely separated. 

In May, 1870,1 removed an ivory exostosis from a young 
woman aged thirty-two, a patient of Mr. Ceely, of Aylesbury, 
whose portrait is given in fig. 160. There had been a pain- 
less enlargement of the left side of the lower jaw for five 
years, and there was also a smaller enlargement of the right 
side. A small exostosis also existed on the left pubes. I 
made an incision behind the jaw and sawed off the growth 



342 NON-MALIGNANT TUMOUllS OF LOWER JAW. 

level to the bone, removing a dense ivory growth measuring 
two inches in length by one inch in widtli, and three-eighths 
of an inch thick in the centre (University College Museum 
635). The exterior of the growth presented a finely reticu- 
lated appearance, and at the upper part was a small depres- 
sion filled with cartilage in the recent state. Two years 
after the operation I was informed by Mr. Ceely that there 
had been no reappearance of the growth, and that the other 

Fig. \r,0. 




exostosis remained m statu, quo, and four years later I saw 
the patient, who continued quite well. 

When the exostosis forms a distinct and circumscribed 
growth, whether it be of the cancellous or ivory character, 
it should be saw^n off the bone at the level of the healthy 
surface, and will in all probability not recur. When, how- 
ever, the whole thickness of the bone is involved, as in Mr. 
Tatum's or Mr. South's case, it will be necessary to remove 
a portion of the bone. Should the tumour be imbedded 
between the plates of the jaw, it should be enucleated if 
possible without any external incision, as in Sir J. Paget's 



OSSEOUS TUMOUES. 343 

case given above. A remarkable case of exostosis of the 
ramus of the jaw, reaching to the styloid process, has been 
recorded by Mr. Syme, in his " Contributions to the Patho- 
logy and Practice of Surgery," in wliich he removed the 
ramus of the jaw, with the gi'owth, by an external incision, 
without opening the cavity of the mouth. 



344 



CHAPTEE XXIII. 

SARCOMATOUS TUMOUES OF THE LOWER JAW. 

Spindle-celled Sarcoma, Myeloid Sarcoma, Clwndro- Sarcoma, 
Ossifying Sarcoma. 

Spincllc-ccllcd sarcoma. This, the old-fashioned osteosar- 
coma, frequently attacks the lower jaw, and may prove 
fatal, by obstruction either to respiration or deglutition, if 
allowed to grow unchecked for many years. Some of the 
earliest removals of portions of the lower jaw were for 
growths of this description which had attained a large 
size, and the names of Crampton, Cusack, and Syme are 
connected with these operations. The Museum of the 
College of Surgeons of Ireland is especially rich in tumours 
of this class, and possesses also a cast of the head of a 
patient who died with a large tumour of the lower jaw, 
which has been injected and divided. The following is the 
description of this preparation (I. a. 361), kindly extracted 
for me by Dr. Barker, the Curator : — " A singularly beauti- 
ful preparation of the osteo-sarcoma of the lower jaw, of 
which the preceding cast gives an outline. The patient 
was a middle-aged woman. The disease commenced as a 
fungus in the alveoli of the front teeth. This fungus was 
removed by operation at an early period, but speedily grew 
again, and in the course of about two years had acquired 
its size, which is equal to that of an infant's head, without 
bursting at any part. It was firm, but elastic to the feel, 
and inconvenienced the patient more by its bulk than by 
its malignancy. The woman, who was naturally of a deli- 
cate frame, gradually sank from exhaustion. No preparation 
could exhibit more satisfactorily the circmnscribed local 



SPINDLE-CELLED SARCOMA. 345 

nature of this affection than that here shown. It is globular, 
four inches in diameter, and enveloped in an osseous wall 
wliicli has connection, exclusively, with the front central 
portion of the lower jaw, and which completely insulates the 
disease. The maxillary bone is perfectly sound beyond the 
points of adhesion of the tumour. The centre of the tumour 
is divided by bony partitions into several chambers, the 
surfaces of which are lined by a pulpy vascular membrane, 
which lias received injection in great profusion. Tlie con- 
tents of these chambers were various — some gelatinous, some 
bloody, and some of a gristly nature, interspersed with bony 
stalactites. Plate 11, in the fourth volume of the Dublin 
Hospital Reports, was taken from this preparation. — Professor 
Wilniot." 

The central portion of this tumour is of such a distinctly 
cystic character that modern pathologists would probably 
have classed the disease among the cystic sarcomata, but I 
prefer to leave it in the place assigned to it by the Irish 
pathologists. 

In the same fine museum are the historically interesting 
tumours removed by Sir Philip Crampton and Mr. Cusack, 
in 1824, the details of which cases will be found in the 
valuable papers by those two gentlemen, in the fourth 
volume of the Dublin Hospital Reports (1827). Sir Philip 
Crampton was the first to insist upon the non-malignancy of 
this form of osteo-sarcoma, and to distinguish it from the me- 
dullary form — up to that time confounded with it. His de- 
scription of the whole course of the disease, as witnessed in 
the jaw, is so perfect that I cannot do better than reproduce 
it : — " The first indication of this formidable disease is the ap- 
pearance of merely a small swelling or projection of the 
gum, between two of the teeth. The teeth, however, soon 
become loose and dislocated, being forced inwards upon the 
tongue, or outwards against the cheek ; as the tumour en- 
larges it assumes a tuberculated appearance, the tubercules 
varying in colour from a light pink to a deep purple ; they 
are firm in structure, perfectly indolent, and do not readily 
bleed even when roughly handled. As the morbid growth 



346 SARCOMA OF THE LOWER JAW. 

extends in all directions, the month is soon filled by the 
tumour, the lower jaw is forced downwards upon the fore 
part of the neck, the tongue is pushed backwards into the 
pharynx, the mouth is carried to the side of the face opposite 
to the tumour, and before the patient sinks under liis suf- 
ferings, a tumour is sometimes formed which nearly equals 
the bulk of the head itself. It is gratifying, however, to be 
able to state that even under such deplorable circumstances 
life has been preserved, and the hideous deformity removed by 
an operation which must be considered as one of the boldest 
and most successful of which modern surgery has to boast. 
But it is from the interned structure of osteo-sarcomatous 
tumours, as developed in the course of operations under- 
taken for their removal, or by dissection after death, that 
the true and distinctive characters of these affections are to 
be traced. In the benign form of osteo-sarcoma, the local 
and, I might almost say, the encysted character of the dis- 
ease is evinced by the distinct line which separates the 
morbid growth from the soft parts with which it is in con- 
tact. It becomes apparent that as the tumour has enlarged, it 
has pushed the soft parts before it, or insinuated itself into 
their interstices, and that, so far from becoming incorporated 
with the surrounding structures, and assimilating them to its 
own nature (as invariably happens in the advanced stage of 
malignant tumours), it has formed attachments so slight, 
that when the portion of bone from whence the tumour 
springs is detached, the whole morbid gi'owth may be (as it 
were) drawn out from the surrounding parts almost without 
the aid of the knife. The interior of the tumour presents 
a great variety of structure, but I should say, in general, that 
the cartilaginous character which the tumour exhibits in its 
origin prevails to the last. In the early stnges of the dis- 
ease the tumour consists of a dense elastic substance, 
resembling fibro-cartilaginous structure, but the resemblance 
is more in colour than in consistency, for it is not nearly so 
hard, and is granular rather than fibrous, so that it ' breaks 
short.' On cutting into the tumour the edge of the knife 
grates against spicula.. or small grains of earthy matter, with 



SPINDLE-CET.LED SARCOMA. 



347 



which its substance is beset. If the tumour acquires any- 
considerable size, it is usually found to contain cavities filled 
with fluids differing in colour and consistency, but in general 
the fluid is thickish, inodorous, and of the colour of chocolate. 
Sometimes the growth of the tumour, or the secretion of 
fluid within its substance, is so slow that the deposition of 
bony matter keeping pace with the absorption, the bone be- 
comes expanded into a large and thick bony case, in which 
the tumour is completely enclosed. There is a beautiful 



FxG. 161. 



Fig. 162. 




preparation of this form of the disease in the Museum of 
the Eoyal College of Surgeons. But in general the walls 
of the cavity consist of cartilaginous structure mixed with 
bone, the bone bearing but a small proportion to the 
cartilage. The extent to which this description of tumour 
may increase without materially affecting the general health, 
is one of the most extraordinary circumstances connected 
with its history" (p. 541). 

The " cartilaginous" appearance here referred to, relates 
only to the naked-eye appearance of the structure, which is 
characteristically said to " break short." Microscopic exami- 



348 SARCOMA OF THE LOWER JAW. 

nation, as I have had the opportunity of observing in a 
large tumour of the kind, shows a dimly granular stroma, 
closely resembling the matrix of cartilage, but containing no 
true cartilage-cells. Though parts of the tumour may show 
structure of this kind, the greater part is usually of a dis- 
tinctly spindle-cell character. 

In 1828 Mr. Syme removed a very large tumour of this 
description (probably the largest which has ever been re- 
moved), weigliing 4|^lbs., which, no doubt, for the reason 
given above, he refers to in a lecture published in the 
Lancet, Feb. 3, 1855, as a fibro-cartilaginous tumour. The 
patient made a good recovery, and the accompanying illus- 
trations, figs. 161 and 162, for which I was indebted to 
Mr. SymCj show his condition before and some years after 
the operation, which was one of the earliest of the kind in 
this country. 

The spindle-celled sarcoma will, if its surface be irritated 
by caustics, &c., throw out fungus masses, which bleed, and 
may be mistaken for malignant fungus. Mr. Cusack {loc. 
cit.) gives an example of this result occurring from slough- 
ing of the skin of the face, due to over-distension by the 
tumour, and I had under my care some years back an 
extraordinary instance of the kind, where quack applica- 
tions had produced similar results. Occasional hsemorrhage 
from such surfaces led to these cases being massed to- 
gether with cancer as examples of fungus Jucmatodes, and 
doubtless Sir William Fergusson's observation is correct, 
that the rarity of fungus htcmatodes in the present day, is 
due to the early treatment to which cases of this kind are 
submitted. 

The portrait of the patient formerly under my own care, 
to whom I have alluded, is shown in fig. 163, taken from 
a photograph, and his case will be found in detail in the 
Appendix (Case XII.). The enormous size of the tu- 
mour can be best appreciated by the figure, the measure- 
ments being as follows : — From the lobule of one ear round 
the chin to the lobule of the other was 19-| inches ; from 
the edge of the lower lip over the chin to the poimim Adami 



SPINDLE-CELLED SARCOMA. 



:U9 



13 inches ; and the width of tlie face was 14 inches. The 
circumference of the lips was 9J inches. The patient was 
only thirty-two, and tlie disease appeared to have commenced 



Fig. 163, 




eleven years before, in a small swelling below the right 
canine tooth, but the whole of the large growth had taken 
place within four or five years. The fungous protrusions 
were, as has been mentioned, the result of the application of 
quack remedies. The patient, when he came under my 
notice, was in a miserable condition, being nearly starved, 
owing to the tumour forming a projecting mass within the 
mouth, which completely concealed the tongue, and was 
nearly in contact with the palate. I succeeded in removing 
the tumour by sawing in front of the left angle and dis- 
articulating on the right side, with very little loss of blood, 
but the patient died exhausted on the sixth day. The 
tumour weighed 41b, 6oz., and is now in the Museum of tlie 



350 



SA.RCOMA OF THE LOWER JAW. 



College of Surgeons (2234). Its appearance (reduced to 
about one-third) is shown in fig. 164. A section has been 
made to show its structure, which is precisely that described 
by Sir P. Cranipton, the mass being made up of fibro-cellular 
tissue of different degrees of density, with here and there 
small nodules of bone, and a few small cysts interspersed 




through its structure. The tumour evidently commenced in 
the interior of the jaw, the outer plate being considerably 
expanded and destroyed in parts, while the inner remains 
perfect, and can be seen in the condition in which it was 
left at the operation. The mass in growing has carried up 



SPINDLE-CELLED SARCOMA. 351 

the teeth with it, and they project from it at irregular 
intervals, a considerable portion of the growth, and probably 
the most recently formed part, being posterior to them, 
occupying as it did the mouth and lying among the muscles 
beneath the tongue. The fungoid masses are covered with 
granulations, but otherwise differ in no way from the rest of 
the growth. 

I was indebted to the late Mr. A. Bruce for the following 
elaborate report upon the structure of this tumour : — " The 
tumour consists of a lobulated mass of soft but elastic con- 
sistence, resembling in parts a recent decolorized fibrinous 
coagulum. It is for the most part of a pale straw-colour, 
with here and there patches of a flesh-tint, and mottled in 
spots with deep crimson. In front is a prominent fungating 
mass, which had penetrated through the skin at the time of 
the operation. The structure consists of a fine fibrinous 
stroma, varying in different parts in its degree of fibrillation; 
in some portions there are very distinct fibres, in others 
only imperfect ones, as is frequently seen in rapidly growing 
parts, whilst in others again the stroma is dimly granular, 
and closely resembles the matrix of cartilage, but differs 
from it in its softness ; this latter character is limited to the 
parts in the interior in immediate connection with the bone. 
Imbedded in this stroma are numerous cells, lying for the 
most part with their axes parallel to one another, but in 
many places without any apparent uniformity in this par- 
ticular. The cells are small in size, at first sight more 
resembling elongated nuclei, but in all cases a cell-wall may 
be distinctly traced when a sufficiently high power is em- 
ployed. The majority are elongated fusiform or fibre cells, 
with a considerable proportion, however, of oval, rounded, or 
even polygonal cells. Their size varies from to iruTyo to-gJ-o inch 
in diameter. The nuclei are proportionately large and pro- 
minent, and contain one or two very distinct glistening 
nucleoli. The cell contents, when any exist, are granular. 
Some of the rounded and polygonal cells closely resemble 
those found in malignant growths, especially in the irregu- 
larity of their arrangement and their large eccentric nucleus ; 



352 SARCOMA OF THE LOWER JAW. 

one cannot, however, lay much stress upon these characters 
in the present case, considering the small proportion which 
these cells hear to the whole mass of the tumour. Frag- 
ments of bone and of calcareous matter are found scattered 
throughout the tumour, and appear to be in part derived 
from the jaw itself, and in part to be a new development. 
The general structure of the tumour is that usually descriljed 
under the head of osteo-sarcoma, and it belongs evidently to 
the group of simple fibro-plastic tumours, but differs from 
the myeloid fibro-plastics in the equal proj)ortion existing 
between the cellular and fibrous elements." 

Mr. Eve has recently re-examined this tumour, and has 
found scattered throughout it masses and cylinders of epithe- 
lial cells, resembling the epithelial elements of the cystic 
tumours of the lower jaw already described (p. 196). They 
were composed of large irregularly shaped or branched masses, 
and of small columns composed of round epithelial cells, 
with a layer of peripheral elongated cells. (For drawing, 
see Lecture by Mr. Eve, British Medical Journal, Jan. 6, 
1883.) 

Under the head of Spindle- celled Sarcoma must be 
included the following two cases, which have hitherto been 
classed as " recurrent fibroid." 

The first occurred in the Westminster Hospital, under 
the care of Mr. Holt, in 1858, in a young woman aged 
eighteen, who had a soft fungoid mass covering the molar 
teeth of the right side of the lower jaw, of ten weeks' 
duration. It apparently sprang from the angle of the 
jaw or the base of the ascending ramus, and had pushed 
the mucous covering before it. The molar teeth were 
firmly fixed in their sockets ; the wisdom tooth was covered 
with gum. The rapid growth of the fungus, and the 
absence of any material pain, led to the conclusion that it 
was probably a form of epulis of a malignant type. Mr. 
Holt therefore thought it advisable to remove the whole 
mass, and examine the bone prior to removal of the jaw 
itself. This being done, its attachments were found to be 
connected with the posterior part oi the body and anterior 



SPINDLE-CELLED SARCOMA. 353 

part of the ascending ramus, the hone heing hard and of its 
ordinary density. Mr. Holt did not feel warranted in doing 
that which he was prepared to do — namely, remove the hone 
at its articulation at this time — but preferred removing with 
the cutting pliers all the hone to which the growth had heen 
attached. Mr. Clendon having then extracted the molars 
and wisdom tooth, Mr. Holt cut through half the thickness 
of the jaw corresponding to those teeth, and, going further 
hack, included the coronoid process, with more than half of 
the sigmoid notch. The disease was found to he intimately 
connected with the ]3eriosteum, whicli readily peeled off", 
leaving the hone somewhat roughened. (See Lancet, Jan. 
28, 1858.) 

The disease reappeared in a few weeks, when Mr. Holt 
was compelled to remove it again, including this time the 
remaining part of the ramus of the jaw. The disease now 
was not confined to the covering of the hone, but extended 
into the pharynx, and was evidently attached to the mucous 
lining of the whole of one side of the mouth. 

The poor girl left the hospital and went to Eeading, and 
died on the 3rd of February. An autopsy was performed 
by Mr. Walford, the particulars of which are given in his 
own words : — 

" Fanny S died on the 3rd, and assisted by Mr. G. 

May, jun., and Mr. Fernie, I made a post-mortem examina- 
tion. I did not open the head. The thoracic and abdo- 
minal viscera were free from disease. I dissected out the 
tumour, which, had the whole of it been there, would have 
completely encircled one side (one-half) of the lower jaw ; it 
extended up to the zygomatic arch and downward into the 
neck. The gullet was free, and it evidently grew into, not 
from, the pharyngeal region. We could not satisfactorily 
discover its origin. The portion of lower jaw-bone left after 
tlie operation was sawn through at the symphysis, and ex- 
hibits the margins of the tumour on the periosteum, which 
I think, must be considered its starting-point, and that, as 
regards treatment, would be practically the bone." (See 
Lancet, March 6, 1858.) 

A A 



354 



SARCOMA OF THE LOWER JAW. 



The second case occurred at the Great Northern Hos- 
pital, in the practice of Mr. George Lawson, who performed 
three operations with the hope of eradicating the disease, 
which, however, eventually proved fatal, as in the preceding 
instance. The patient was a young woman aged seventeen, 
and the first operation was performed October 4, 1858. 
She had then wliat might be termed a large epulis growing 
from the anterior and inner surface of the ascending ramus 
of the lower jaw on the left side, extending from a point 
near the angle to close upon the condyle. Mr. Lawson re- 
moved the tumour witli bone-forceps, cutting away appa- 
rently all its bony attachments. About six weeks after the 
first operation a small elastic mass appeared in the temporal 
fossa of the aiiected side, but the jaw was apparently free. 
This Mr. Lawson excised, but found tliat the growth had 
evidently sprung from its original site, and extending up- 
wards, had passed beneath the zygoma into the temporal 
fossa. The third operation was in June, 1859, when, in 
consequence of the great size the tumour had attained, the 
inability of the girl to open her mouth, and the great diffi- 
culty she experienced in deglutition, Mr. Lawson removed a 
portion of the inferior maxilla, sawing through the bone in 
front of the angle, and then disarticulating. Upon the 
removal of this portion of bone (fig. 165), it was found that 

Fig. 165. 




the tumour had formed so many attachments to the perio- 
steum of the bones forming the base of the skull, that the 
operator was compelled to leave some of the disease behind. 
By the end of iSToN'ember, 1859, the tumour had again 



SPINDLE-CELLED SARCOMA. 



355 



grown to a large size, and from the space it occupied in her 
mouth interfered much with her taking nourishment. It now 
began to soften and to ulcerate on its surface, both externally 
and within the mouth, and occasionally very alarming 

Fig. 166. 




haemorrhages would take place, so as to threaten imme- 
diate dissolution, but from all these she rallied ; within the 
mouth large sloughs would occasionally separate, allowing 
her to recruit her health by enabling her to take additional 
nourishment. She died early in 1860, worn out and greatly 
emaciated. The drawing (fig. 166), for which I am indebted 
to Mr. Xawson, shows the terrible deformity as seen after 

A A 2 



356 SARCOMA OF THE LOAVER JAW. 

death. The preparation is in the ]\Iuseiim of the College 
of Surgeons (2230 A). (See Pathological Transactions, xi.) 

In Mr. Lawson's case, repeated careful examinations of 
the tumour proved it to be of the so-called recurrent fibroid 
character, and the rough and thickened condition of the peri- 
osteum covering the portion of bone which was removed, 
showed clearly the site from which the tumour gi-ew. Mr. 
Holt's case, which is remarkably similar in all essential 
points, is reported as one of malignant disease ; but from 
personal observation, I believe it to have been an example 
of recurrent fibroid disease, rather than any form of true 
cancer. The two cases are as nearly alike as they could 
possibly be, and were doubtless of the same nature. 

The treatment of this form of disease must be unsatis- 
factory. The tendency to invade the tissues continuous 
with and contiguous to the original seat of the disease, ren- 
ders any operative interference of doubtful utility. Still 
the only hope for the patient is complete extirpation of the 
disease at an early period, and the operation should include 
tlie entire thickness of the bone from which the growth arises. 

The following museum specimens of recurrence of the 
spindle-celled sarcoma, after complete removal, may be con- 
veniently noticed here. 

In the Museum of the College of Surgeons is a prepa- 
ration (2224) of the right side of a lower jaw, from the 
angle to the bicuspid tooth, which, with a tumour upon it, 
was removed by Mr. Listen. The tumour, which measures 
about two inches in its greatest diameter, is situated almost 
entirely on the anterior surface of the jaw, projecting for- 
wards and upwards, and extending along nearly the whole 
length of the portion removed. The greater part of the 
tumour consists of a pale, firm, and compact substance : at 
its base it is osseous, and so closely attached to the anterior 
surface of the jaw, from which it appears to have risen, that 
the outline of the latter can scarcely be made out. The 
patient was a woman of thirty, who had had a blow on the 
cheek nine years before the tumour appeared. Its growth 
was accompanied by lancinating pain in the jaw and con- 



MYELOID SARCOMA. 357 

tinual headache. It was removed five months after its first 
appearance. No portion of the disease appeared to have 
heen left, but the growtli reappeared in the ramus, and ne- 
cessitated its removal by disarticulation ten months after- 
wards (2225). 

In St. Bartholomew's Hospital Museum is a specimen 
(I. 442) of a tumour, for which the right side of the jaw 
from the angle to the symphysis was removed. The morbitl 
growth consists of a grey, dense, fibrous substance originating 
from the alveolar border, and from the outer surface of 
the jaw. Part of the alveolar border of the jaw has been 
absorbed ; and in this situation the morbid growth appears 
to extend into the bone, which is harder than usual. It 
was removed from a woman aged thirty. Subsequently a 
tumour formed in the side of the neck immediately below 
the seat of the operation, wliich ultimately proved fatal by 
the ulceration and sloughing which took place in it. A 
portion of this was connected with the jaw, and a section 
shows it to consist of a firm fibrous substance. 

Myeloid Sarcoma is frequently met with in the lower jaw, 
and it was here that the disease occurred in the case from 
which Sir J. Paget drew his description. The case is quoted 
by Mr. Stanley (op. cit. p. 184) as an example of "tumour 
of bone, composed of a soft, very vascular substance, having 
the characters of erectile tissue," but his general description 
corresponds precisely to that of Sir J. Paget. Pigs. 1 and 
2 of Plate 13 in Mr. Stanley's atlas show the tumour in 
situ and a section of the jaw after removal. " The patient 
was a boy in St. Bartholomew's Hospital, and the growtli 
occupied the symphysis of the lower jaw, and protruding 
into the mouth presented a very vascular surface of a mottled 
red and purple colour, resembling the exterior of some nievi. 
The tumour was not tender to the touch, and had not been 
accompanied by pain ; it was once destroyed by caustic to 
the level of the alveolar border of the jaw, but was quickly 
reproduced ; it was then wholly removed with the portion of 
the jaw in which it originated, and tlie cure was permanent. 
The morbid substance was found imbedded in the cancellous 



358 



SARCOMA OF THE LOWER JAW. 



texture of the jaw ; it was soft, of a dark red colour, closely 
rcsemUing the tissue of healthy spleen." (Stanley, p. 185.) 

Stanley mentions a case, very similar to his own, recorded 
by Dupuytren in his Legons Orales; and in the Museum of 
St. Thomas's there is a very good specimen of myeloid 
disease, which was described by Sir Astley Cooper ( " Surgi- 
cal Essays") as " a fungous exostosis of the lower jaw, Mdiich 

Fig, 




formed a large prominence on the chin" with " purple fungi 
of the gums," occurring in a woman aged thirty-two. The 
preparation shows at the back part a small portion of firm, 
healthy bone, having a well-defined margin and not sending 
out any spicula, from which the tumour projects. Around 
its base the tumour is covered with integument ; but in front 
the latter has ulcerated, allowing the growth to fungate 
through the ulcerated aperture. 

A valuable preparation is in the College of Surgeons' 



MYELOID SARCOMA. 359 

Museum (421) of myeloid tumour of the symphysis, and 
body of the jaw, removed by Mr. Craven, of Hidl, from 
a young woman of eighteen, who made a good recovery 
after the operation. Figs. 1G7 and 168 show very satis- 
factorily the appearance of the specimen, whicli has been 
divided horizontally. The tumour was of between two and 
three years' growth, and was covered with liealthy mucous 
membrane. Its section shows a well-marked specimen of 
myeloid disease imbedded between the plates of the lower 
jaw ; its tissue is of the ordinary friable character, resembling 
spleen, but somewhat decolorized by immersion in spirit, and 
it is intersected by fibrous septa. Two cysts may be seen in 
the section ; these, as mentioned by the late Mr. H. Gray 
{Medico-Chirurgical Transactions, xxxix.), being of frequent 
occurrence in myeloid growths. The microscopic examina- 
tion of Mr. Craven's specimen was unsatisfactory, owing to its 
previous immersion in spirit, but there can be no question, 
from the naked-eye appearances, of the nature of the growth. 

In the Museum of St. George's Hospital are four speci- 
mens of myeloid disease affecting the lower jaw (II. 166, 
167, 168, 169), two of which have no history; the others 
were removed from girls of eight and five years respectively, 
of whom the first was known to be well two and a half years 
afterwards. In the Museum of University College are three 
excellent specimens, removed by Liston (680, 1, 2), and there 
are three in St. Bartholomew's Hospital, all from young 
persons. 

Myeloid disease, if not very freely removed, may recur, 
however, as in a case of Sir William Fergusson's, which 
occurred whilst I was his house-surgeon, and of which the 
particulars will be found in the Lancet, June 13, 1857. The 
patient, a young woman of twenty-three, had undergone a 
previous operation, but it was doubtful if the whole of the 
disease had then been removed. She presented a tumour of the 
right side of the lower jaw (fig. 169). Sir William Fergusson 
removed the tumour by sawing through the jaw at the canine 
tooth and disarticulating, but the patient unfortunately sank 
on the following day from exhaustion. The following is a 



360 SARCOMA OF THE LOWER JAW. 

description of tlie tumour, which proved to be myeloid, 
extracted from the published report, but it maybe remarked 



Fio. 169. 




that the colour hardly bears out the diagnosis of myeloid 
disease as ordinarily met with : — " It has been developed 
within the bone, which it has expanded into a thin enve- 
lope of compact bony tissue clothing its exterior. A section 
showed a surface of a clear white colour, bathed with clear 
serum (not milky when scraped), of considerable firmness, 
and presenting numerous osteoid deposits. — Minute structure: 
It is almost wholly built uj) of small cells, whose prevalent 
form is oval, either free in a dimly granular matrix, or, here 
and there, contained in large parent cells, resembling those 
of foetal marrow. Very delicate fibres occur sparingly." 

A remai'kable, and I believe unique, examj^le of disease 
of both sides of the lower jaw, the microscopic characters of 
which were decidedly myeloid, was formerly under my 
own care, of which the following are the brief particulars'. 
The patient, a l)oy of seven and a half, whose portrait is 
shown in fig. 170, presented a remarkable enlargement of 
both sides of the lower jaw, giving his face a very square 
appearance. The affection had come on gradually and pain- 
lessly from the age of a year and a half, and at the time I 



CHONDEO-SARCOMA. 



361 



operated upon him the width of the jaw, as measured with 
callipers, was five inches, the width of an average adult jaw 
being only four inches. The growths were evidently pro- 
jections from the outer surfaces of the angles of the jaws, 
the inner surface of the bone being natural, and the 



Fig. 170. 



Fig. 171. 





mucous membrane of the mouth not interfered with. In 
September and October, 1867, I removed the right and 
afterwards the left tumour through incisions behind the 
margin of the jaw, and without opening into the mouth. 
The main part of each projection was sawn off the jaw, 
and are now in the College of Surgeons' Museum (2232), 
closely resembling large mussel -shells filled with a 
cartilaginous-looking substance, which, however (and espe- 
cially some darker portions) gave distinct microscopic evi- 
dence of myeloid structure. A good deal of this material, 
which seemed to fill the interior of the bone, was gouged 
away, and the symmetry of the face restored as far as 
possible. The boy made a good recovery, and fig. 171, from 
a photograph, shows his condition three months after the 
second operation, and there appears to have been no ten- 
dency to recurrence. The case is given in detail in the 
Appendix, Case XIII. 

Chondrosarcoma is characterized by rapidity of growth 



362 SABCOMA OF THE LOWER JAW. 

and by early recurrence after removal. The primary tumour 
is mainly encliondroma, but the recurrent growths are chiefly 
composed of small round-celled sarcoma, which tend to pro- 
duce internal deposits through the vascular system. 

The following good illustration of the disease occurred 
under my own care. A woman, aged forty-four, was ad- 
mitted into University College Hospital on April 11, 1877, 
with the following history : — She first noticed a swelling 
connected with the left side of the lower jaw nine months 
before. The swelling was painful, and accompanied by 
numbness over the chin. Twenty years before she had 
received a violent blow over the jaw, when attendant in a 
lunatic asylum. The family history threw no light on the 
case. The patient had always enjoyed good health. 

On admission, there was a large tumour over the left side 
of the lower jaw, and firmly connected with the inner and 
outer surfaces of the bone, extending fi'om an inch behind 
the symphysis to the angle. The growth generally was firm 
and elastic, though some parts were much softer than others. 
The border of the tumour was well defined, and the skin was 
freely movable over it. A nodule, the size of a walnut, 
projected between the teeth into the cavity of the mouth. 
The patient complained of shooting pains in the tumour, 
which ran along the lower lip. There was no enlargement of 
lymphatic glands, and no other tumour. The general health 
was good. Tlie patient's appearance is shown in fig. 172. 

On April 14th I removed the tumour with the bone in- 
volved, from the left of the symphysis to an inch above the 
angle, and the patient made a good recovery. 

Eleven weeks after discharge she was readmitted. The 
lower borders of the segments of the previously divided jaw 
had united by fibrous union, but a V-shaped notch existed 
at the u[tper border large enough to admit the tip of the 
finger. Eecurrence of the growth had taken place in con- 
nection with both divisions of bone. There was a timaour as 
large as a hen's egg beneath the chin, but this could not be 
felt through the mouth, whilst a second and larger one 
caused bulging of the left cheek, and was mainly situated 



CHOKDRO-SARCOMA. 



363 



over the ramus of the jaw ; it projected into the oral cavity 
and rendered articulation indistinct, although there was no 



Fig. 172. 




difficulty in deglutition. The skin was freely movable over 
both masses ; there was merely a linear cicatrix at the line 
of the old incision. The lymphatic glands were not en- 
larged, and the general health was good. 

A second operation was done on August 1, 1877. It 
being found impossible to remove the tumour by the mouth, 
I made an incision along the lower border of the jaw, 
from two inches to the right of the symphysis for a 
distance of six inches. The lower lip was dissected from 
the bone and turned upwards, and the jaw sawn through 
at the symphysis, which allowed a piece on the left to be 
removed with growth attached. It was found that the 
whole of the posterior mass could not be removed, as it 
extended deeply into the pterygoid region, so after enu- 
cleating as mucli as possible, the operation was not further 
proceeded with. The wound was syringed out with strong- 
solution of chloride of zinc, and then plugged with lint. 



364 SARCOMA OF THE LOWER JAW. 

For the first fourteen days the wound continued to heal 
rapidly, but at this time it commenced to fungate, and on 
the twentieth day sharp bleeding ensued, which required the 
actual cautery to arrest it. Severe pain was more or less 
constant, and the discharge very fetid. On the 28th the 
fiingating mass reached the clavicle, and completely hid the 
left side of tlie neck ; hai-niorrhage again occurred, and the 
cautery was employed. 

In spite of a supporting ]~>lan of treatment the general 
liealth rapidly failed, the patient fell into a semi- comatose 
condition, got more and more asthenic and cacliectic, and 
died on the forty-third day after the second operation. 

Autopsy. — The mass of growth exteuded from the zygoma 
downwards for over seven inches, and was from five to six 
inches in thickness. Another tumour sprang from the right 
segment of the divided jaw, and the left side of the tongue 
and floor of the mouth were largely invaded. The upper 
jaw was not involved, but only imbedded in the growth, 
which had forced itself deeply amongst the neighbouring 
parts, where the veins were filled with firm white clots, but 
no gro^A'th had sprung up in connection with their walls. 
The tumour, on section, varied in colour, being yellowish- 
wliite in some parts, whilst it was red and vascular in others, 
and mottled with patches of extravasated blood. It weighed 
2 lb. 3 oz. There were two nodules of secondarj^ growth in 
the left lung, and three larger ones in the right lung. One 
of these was distinctly seen to be lying in the course of a 
good-sized branch of the pulmonary artery, whose walls 
were expanded over it. It did not completely block the 
lumen of the vessel, and on its surface was a white fibrinous 
dejDosit. 

The mass removed at the first operation consisted chiefly 
of enchoudroma, with a dim hyaline and fibrous matrix, 
but interspersed with islets of round-celled sarcoma. The 
recurrent masses were made up chiefiy of round and spindle- 
celled sarcoma, whilst scattered throughout were isolated 
portions of cartilaginous tissue, with fibrous matrix. 

Ossifying sarcoma, in which ossification takes place ex- 



OSSIFYING SARCOMA. 



365 



tensively in a matrix of sarcomatous tissue, occurs in the 
lower jaw, and, as in the foUowing case, presents at first 
most of the characters of an ordinary osteoma. Fig. 173 
shows the portion of lower jaw at first removed, with a 



Fig. 173 




section of the tumour, which it is diificult to distinguish 
from ordinary bone, except by the striation seen best at its 
margins. The rapid recurrence of the disease in a soft form 
showed the true nature of the case, and the patient died 
exhausted within a year of the first operation. 

W. G — , aged fifty, was admitted into University 
College Hospital on May 9, 1881. About five months 
previously he noticed a pricking pain about the left 
side of the lower jaw, and soon a lump appeared outside 
the bicuspid teeth ; it grew steadily but slowly, until one 
month before admission. At tliis time the patient had 
several teeth extracted, and the increase in the size of the 
growth became rapid after this interference ; there was 
constant gnawing pain. The patient believed exposure to 
cold to have been the cause of the swelling. Both his 
parents died of " old age," and had no kind of tumour. 

On admission the lower part of the left cheek was bulged 
outwards considerably by a very hard rounded swelling, 
which covered the outer side of the left half of the lower jaw 



366 SAKCOMA OF THE LOWER JAW. 

from a short distance in front of the angle almost to the left 
canine ; the lower edge of the Lone was concealed by slight 
projection of the mass below it ; and on pressing upwards in 
the submaxillary region a considerable swelling could be 
felt on the inner side of the bone. Altogether the impres- 
sion conveyed to the fingers was that the grow^th was 
central, and that the so-called expansion of bone had 
occurred over it. 'No teeth were present on the left side 
behind the canine, the alveolus was widened, and presented 
posteriorly several low, rounded swellings, covered by 
mucous membrane, soft or even cystic ; whilst in front lay a 
large crater-like ulcer, at the bottom of which no bone was 
bare. The tongue and floor of the mouth were normal. A 
small, not tender, gland could be felt behind the angle of the 
jaw. There was moderate constant pain in the part, much 
increased by hanging the head down. As regards general 
health there was nothing to be desired. 

On ]\Iay 11 ether was given, and the growth removed by 
an incision from the left angle to the symphysis ; the jaw 
was sawn through to the left of the symphysis, the soft parts 
stripped from the growth, and then the bone was divided 
near the angle. The wound was closed by wire sutures, 
and dressed with cotton wool. 

The wound was all but healed on the eighth day, quite so 
on the twentieth, w^hen the man left the hospital feeling quite 
well. 

The growth was smooth on the surface, and covered by a 
thin layer of fibrous tissue ; it was subperiosteal, not central, 
and on the inner side of the jaw lay two long oval masses, 
parallel to the mylo-hyoid ridge — one above, one below it. 
A section of the large outer mass show^ed it to consist of 
solid bone, much denser than ordinary cancellous tissue, 
surrounded by a margin of soft greyish-yellow tissue, 
nowhere more than a quarter of an inch thick. Vertical 
striation was plain in this border, and was in part due to 
spicules of bone. On the alveolar border was a layer of 
similar soft growth, one-third to half an inch thick. Micro- 
scopically the growth consisted of rather large round and 



OSSIFYING SARCOMA. 367 

polygonal cells, surrounded by bands of spindle cells, and 
tracts of fairly developed connective tissue ; so that to the 
naked eye a section, seen by transmitted liglit, was made 
up of distinct lobules. The above description refers to the thin 
soft layer on the surface, and even in its substance dots of bone 
were numerous ; whilst at its base lay a large mass of deep 
yellow bone, fairly dense, having large lacunas and ill-deve- 
loped canaliculi ; tumour cells occupied the cancellous paces. 

Soon after leaving the hospital the patient's face swelled a 
good deal, and it was thought that recurrence of the growth 
had occurred ; but a sequestrum worked out, and the swell- 
ing subsided. In three months, however, he was readmitted, 
having had a distinct recurrence for six weeks, with much 
constant pain. His health was still very good. 

On September 6, 1881, the left side of the face was now 
swollen from two inches below the line of the jaw to above 
the level of the ala nasi, and from the symphysis to the 
lower end of the ramus of the jaw. On looking into the 
moutlr, two large firm masses of growth were found — one 
above the old scar, lying in the cheek, and running back 
almost to the anterior pillar of the fauces; the other, below 
the scar, occupied the floor of the mouth. They were 
separated by a deep groove, at the bottom of which was a 
little ulceration ; elsewhere, the surfaces of the growths were 
slightly lobulated and covered by mucous membrane. 

No large glands were felt. On the following day the 
whole of this mass, together with the ramus, coronoid pro- 
cess, and condyle of the jaw, were removed by the ordinary 
incision for the removal of half the lower jaw. 

The patient again recovered, without any bad symptoms. 
The hinder part of the wound gaped widely, but it was 
healing steadily, and there was no obvious recurrence on 
October 8, when the patient left the hospital. 

The left angle and ramus of the jaw were surrounded on 
all sides by masses of new growth, in which there was very 
little bone, as far up as the base of the coronoid process. 
In the mass which lay below the scar, unconnected with the 
jaw, there was a large proportion of bone. Microscopically, 



3G8 SARCOMA OF THE LOWER JAW. 

the groM'th Wcis very similar to tlie primary one ; there was 
less division into lobules, and the cells were, perhaps, 
smaller ; the bits of bone seen were much less perfect. 

On January 30, 1882, the patient was again admitted, 
having noticed a recurrence of tlie growth two months. The 
left cheek was now enormously swollen, and the angle of the 
mouth pushed forwards by a mass of new growth^ fungating 
into the mouth along the line of the jaw, but elsewhere 
covered by mucous membrane. The old wound was healed, 
but for an ulcer an inch and a half by half an inch, round 
which there was a good deal of firm infiltration at its 
posterior end. The growth was firm and elastic at some 
points, bony at others, adlierent to the symphysis, but not 
very firmly. The whole face was oedematous ; the left tem- 
poral fossa rather full, and tlie seat of much pain. The man 
was still pretty strong. 

On February 2 the old incision was opened up, and the 
main part of tlie growth turned out. As the skin was 
stripped up, the hau'-bulbs could be seen springing out of 
the tumour ; then a piece in the floor, on either side of the 
frsenum, was removed, and the two ranine arteries cut and 
tied. When the tongue had been drawn forwards by a 
string, the symphysis was removed to just beyond the right 
canine tooth ; and, finally, an attempt was made to remove 
the posterior end of the tumour ; but, as it here seemed to 
involve the tonsil and carotid vessels, and to spread into the 
temporal fossa, much had to be left. 

Again the patient made a good recovery. The anterior 
part of the wound healed, but the posterior gaped widely, 
and he went out with a large hole here. Pain in the tem- 
poral region continued. He died at home on April 5, having 
been able to walk up and down stairs to the last. The 
total duration of the disease would, therefore, seem to have 
been about seventeen months. A section from the second 
recurrence was more densely round-celled than either of the 
preceding specimens ; slight traces of lobulation remained, and 
there was a large amount of rudimentary bone. Tlu-oughout 
the vessel-walls were formed by cells of the new growth. 



369 



CHAPTER XXIV. 

MALIGXANT TUMOUKS OF THE LOWER JAW, 

Bound-Gelled Sarcoma and Einthelionia, 

Bound-celled or Medidlary Sarcoma begins usually in the 
interior of the bone, producing rapid expansion of it, and 
ultimately breaking through into the mouth, and also 
through the skin of the face if allowed to proceed un- 
checked, A specimen in University College Museum {QQQ) 
is a good example of the disease. The morbid growth 
projects chiefly on the outer side, and its most prominent 
part has protruded through the skin, forming an overhanging 
nummular projection which has an open reticular surface. 
On the inner side the tumour has invaded the jaw, in p]|aces 
destroying its entire thickness ; the growth, however, 
scarcely projects into the mouth. As seen on the divided 
surface, it is composed of a soft, granular, yellowish basis, 
supported and parted into small polyhedral masses by 
narrow lines of fibrous tissue ; its lunit is everywhere de- 
finable. Microscopic examination shows the tumour to 
liave all the characters of a large round-celled sarcoma. 

Many of the museum specimens hitherto described as 
medullary cancer are really examples of round-cell sarcoma, 
and the following case of Mr. Listen's, in the College of 
Surgeons (2230), may be quoted as an instance of the size 
to which round-celled sarcoma may grow. " Part of a lower 
jaw, including the left condyle, the alveolus of the right 
first molar tooth, and all the intermediate parts which, with 
an enormous tumour upon them, were removed by operation. 
The left ascending portion and side of the jaw, as far as the 

B B 



370 MALIGNANT TUMOURS OF LOWER JAW. 

canine tootli, are completely enclosed by the tumour, and it 
covers both surfaces of the jaw as far as the right canine 
tooth. A round lobulated mass projects downwards and 
forwards, and in the opposite direction the tumour projects 
into the mouth witli a rough fungous surface, in which a 
displaced molar tootli is seen. The interior of the tumour 
is indistinctly lobulated, composed of round masses con- 
nected by cellular tissue, and of a soft texture ; it is in- 
vested by a thick capsule." 

I had under my care a very interesting case of medullary 
sarcoma of the lower jaw, in a little girl, aged five — one of 
a numerous and healthy family, who was in perfect health 
until seven weeks before I saw her. The mother then 
noticed that the second temporary molar tooth on the right 
side was loose, and the gum swollen ; and a tumour de- 
veloped so rapidly, that when I saw her the side of the face 

Fig. 174. 




was considerably enlarged, and a large fungous mass pro- 
truded into the mouth. On September 10, 1867, I re- 
moved the right side of the jaw from close to the symphysis 
to the articulation, and the preparation is now in the 
INIuseum of the College of Surgeons (1057 A). The structure 
of the growth was distinctly medullary. The child made a 
perfect recovery, and was well for six weeks, when a small 
growth was noticed within the cheek, which made such 
rapid progress tliat in four days, when she was brought up 
to me aeain, there was a tumour filling the cheek, and 



ROUND-CELLED SARCOMA. 371 

involving the remaining portion of the jaw as far as the 
canine toothy and a fungus had been thrown out through a 
portion of the old cicatrix. 

On Oct. 26, 1867, I removed the whole of the disease 
again, cutting the jaw on the left side immediately in front 
of the second molar tooth, and removing the whole of the 
skin involved in the fungus. Tlie patient made a good reco- 
very, and fig. 174, drawn from a photograph taken seven 
weeks after the second operation, shows her then con- 
dition, which was quite satisfactory, there being no evidence 
whatever of return, and very slight deformity, considering 
the amount of jaw removed. 

The second growth, which was even more markedly me- 
dullary than the first, is preserved with it. 

The child continued in perfect health to the end of the 
year, but early in January, 1868, the disease reappeared, both 
at the symjDhysis and in the masseteric region on both sides. 
Coupled with this there was loss of appetite, great exhaustion, 
and irritability of the system ; and the poor child gradually 
sank, and died on Feb. 9, a little more than six months after 
the first appearance of the disease. The full particulars of 
this case will be found in the Appendix (Case XI.V.). 

This case appears to me of considerable interest, since it 
shows the advantage of surgical interference, even under 
desperate circumstances. If the first growth had not been 
removed, the patient would have been shortly destroyed by 
the fungus in the mouth, whereas the operation gave her 
six weeks' immunity from suffering. The return of the dis- 
ease was of such a rapid nature, that it would in a very few 
days have destroyed the patient by hemorrhage from the 
fungus which had already begun to form in the skin ; but 
the second operation again relieved her, and restored her to 
comfort and apparent health for more than two months. 
Wlien the disease finally appeared on both sides of the face, 
it was obviously beyond surgical control, and rapidly de- 
stroyed the patient. The relief which the operations 
afforded was, however, gratefully acknowledged by the friends 
of the little patient. 

B B 2 



372 MALIGNANT TUMOURS OF LOWER JAW. 

Epithelioma occurs in the lower jaw in two forms, the 
cohmmar and the squamous. Columnar epithelioma occurs 
in connection with multilocular cysts and with single cysts, 
and has been already fully discussed (p. 205). Squamous 
epithelioma is the more common form of disease, and is 
found both in connection with ulceration of the gums (p. 254) 
and as a tumour of the jaw. The following, under my own 
care, is a typical case of the latter form of the disease. A 
man, aged fifty-six, first noticed a swelling in his face four 
months before his admission ; he used to have toothache, 
and had lost all the teeth behind the left lateral incisor in 
the lower jaw. Wlien first noticed, the tumour was about 
the size of a small walnut, and was situated on the left 
ramus near the angle of the jaw. It was not painful or 
tender to the touch, but grew steadily. On admission to 
University College Hospital there was on the left side of the 
lower jaw a rounded, smooth swelling, which extended from 
the middle of the vertical ramus of the jaw to the level of 
the hyoid bone below, and forwards nearly to the symphysis. 
The swelling was firm and inelastic, and the skin over it 
was normal, except that it was slightly reddened over the 
anterior half of the growth. Inside the mouth the growth 
projected as a large red roundish mass, with the surface 
flattened and sloughy. It reached as far backward as the 
vertical ramus, and encroached upon the floor of the mouth. 
I removed the tumour, with the portion of the lower jaw 
implicated, by dividing the lower lip in the median line 
and carrying an incision beyond the angle of the jaw. The 
jaw was sawn to the right of the median line, between the 
incision and the canine teeth, and the tongue being secured 
with a thread, the bone was disarticulated on the left side 
with some little difficulty, owing to the tumour breaking 
away from the upper part. Consequently the coronoid 
process was nipped off with bone-forceps, and an elevator 
was used to lift the condyle out. There was very little 
bleeding, and only one or two ligatures were applied. 
The wound was sprinkled with iodoform, and brought together 
with wire sutures, drainage being provided for. 



EPITHELIOMA OF LOWER JAW. 373 

The patient made an uninterruptedly good recovery and 
left the hospital in thirty days. 

The part removed consisted of the remains of the left half 
of the bone, the part between the vertical ramus and the 
central incisors being almost entirely destroyed by the 
growth, only a shell of bone remaining at each end. On 
section the growth was of a dead white colour where oldest, 
with a firm margin advancing into the surrounding tissues. 
It consisted of a fibrous stroma, in which were scattered 
numerous leucocytes and spindle cells, with large masses of 
squamous epithelium cells, many of which were collected into 
bird's-nest groups. The specimen is in University College 
Museum. 

The general characters of squamous epithelioma of the 
jaw are well seen in the foregoing case. Eapidity of growth, 
with destruction of the bone, and fungation into the mouth, 
are the leading characteristics, and nothing but early and 
free removal offers any chance of relief. In the above case 
the jaw in its upper part was apparently healthy, but I had 
no hesitation in disarticulating so as to be thoroughly beyond 
the disease, and I also went well into healthy bone at the 
point of section so as to avoid, as far as possible, all risk of 
recurrence. 

The question of the necessity for the removal of large 
portions of bone in cases of cancer of the lower jaw may be 
here referred to. Some surgeons maintain that, in a case of 
cancer, it is necessary to amputate at the joint above the 
disease in order to obtain immunity, But, if this doctrine 
is to be carried out fully, the entire lower jaw should be 
removed for disease of one side, for though the bone was 
originally developed in two halves, there is nothing to pre- 
vent malignant disease spreading across the symphysis, as 
was seen in the case of epithelioma under my own care. 

It certainly is essential that in dealing with cancer of 
the lower jaw the surgeon should go beyond the disease, 
and not meddle with the growth itself. A preparation 
(College of Surgeons' Museum, 2231 A), is an instance 
in point. It was removed, post-mortem, from a man who 



374 MALIGNANT TUMOURS OF LOWER JAW. 

died under my care, with periosteal medullary sarcoma of 
the right side of the lower jaw. He had a swelling of 
the gum in the region of the molar teeth^ which was 
thought by a dentist of repute to depend upon the irritation 
of some stump of a tooth. The growth was therefore in- 
cised, and a prolonged search made for the suspected fang, 
without result. The effect of this treatment was to excite 
very considerable action in the parts, the tumour rapidly 
increased in size, discharging large quantities of fetid matter, 
and a considerable piece of necrosed bone could be detected 
with the probe. The patient, wlien he came under my 
notice, was not in a condition to bear any operative inter- 
ference, and shortly died. The preparation shows a malig- 
nant tumour surrounding the greater part of the right side 
of the jaw, the bone within being in a state of necrosis, 
and the condyle and part of the coronoid process having 
entirely disappeared. 

The lower jaw is liable to be invaded by epithelioma 
spreading to it from the tongue and lip, and may be affected 
by both epithelioma and sarcoma developed in the neigh- 
bouring lymphatic glands. 

On more than one occasion I have found epithelioma of 
the anterior part of the tongue attached to and infiltrating 
the central portion of the lower jaw, and have been obliged 
to cut out the incisive region with good result. The most 
remarkable case was one, the details of which will be found 
in the Appendix (Case XV.), of a man, aged fifty-two, who 
was under my care in 1875 with extensive epithelioma of 
the front of the tongue, which was firmly fixed by its tip 
to the lower jaw, with great enlargement of the sub- 
maxillary glands and infiltration of the submaxillary tissues. 
He suffered acutely from occipital pain, which it is difficult 
to explain, and was willing to submit to any operation for 
relief. I divided the jaw on each side 1^ inch from the 
symphysis and then removed the front of the tongue^ the 
centre of the jaw, and all the sublingual structures with the 
galvanic ecraseur (University College Museum, 1023). The 
patient made a rapid recovery, the two portions of jaw fell 



EPITHELIOMA OF LOWER JAW. 



375 



together, and are now united at an angle by tough fibrous 
tissue, and the man, who was alive and well in 1883, has 
covered the deformity by growing a beard. 

In January, 1879, 1 performed nearly as extensive an opera- 
tion on a man, aged sixty-eight, removing the lower jaw from 
the right incisors to the left angle, for extensive epithelioma 
of the jaw and floor of the mouthy the patient making' a 
good recovery and being in perfect health two years later, 
but dying with recurrence of the disease eventually {Lancet, 
November 20, 1880). 

In the cases of recurrent epithelioma of the lip, Avhen 
the disease shows itself in the submental glands, which 
become adherent to and implicate the bone, it is possible to 
give relief, for a time at least, by sawing out the portion of 

Fig. 175. 




bone involved, as I did in an old man in May, 1876. 
In two instances I have sawn off the chin only, without 
breaking the line of the alveolus, or opening the cavity of 
the mouth. Fig. 175 shows the first patient on whom I per- 



376 MALIGNANT TUMOURS OF LOWER JAW. 

formed the operation, and the details of the case will he 
found in the Appendix (Case XYI.). 

Sarcomatous growths in the submaxillary lymphatic 
glands tend, after a time, to implicate the lower jaw, of which 
it may be necessary to remove a portion \\dth the tumour. 
A specimen (2254) in the Museum of the College of 
Surgeons is the left half of a jaw-bone, the body of which 
has been, to a gxeat degree, destroyed by the growth of a 
firm substance, which appears to have been developed on 
the exterior of the bone, and to have gradually produced 
ulceration and necrosis of it. At the angle of the jaw, 
adjacent to the growth, the bone is deeply and irregularly 
ulcerated, and near the symphysis several portions of it are 
completely detached. The patient was a man of forty-five, 
and the disease began in a hard enlargement in the situation 
of the submaxillary gland. After increasing for a year it 
extended into the mouth, where a fungous growth protruded, 
and subsequently the integuments of the cheek sloughed 
and rapidly ulcerated, and the patient died exhausted. 
After death secondary growths were found in the lungs and 
liver. 

By the kindness of Mr. "Wilkes, of Salisbury, I was en- 
abled to send to the College of Surgeons' Museum (2251) a 
tumour near the angle of the jaw, for which that gentle- 
man amputated one-half of the bone, which w^as exhibited 
to the Pathological Society of London, in May, 1862. The 
patient was a man of fifty, who had a globular mass below 
the middle of the horizontal ramus of the jaw, adherent to 
the bone, but movable. The angle of the jaw was roughened 
near the growth. After removal of the half of the jaw the 
tumour was found to be enclosed in a thick fibrous capsule, 
connected with the periosteum. Microscopically the tumour 
was composed of very small round cells, with very little 
stroma. It was probably a lympho-sarcoma, and may have 
originated in the submaxillary lymphatic glands. 

Mr. Coates, of Salisbury, was also kind enough to place 
at my disposal another specimen of growth connected with 
the lower jaw, which is also in the College of Surgeons' 



EPITHELIOMA OF LOWER JAW. 377 

Museum (2252). The patient, a man aged sixty-seven, was 
admitted into the Salisbury Infirmary in November, 1863, 
with a tumour of the riglit side of the lower jaw, for which 
amputation of one-half of the bone was performed by Mr. 
Coates. The patient unfortunately sank eleven days after 
the operation. The tumour is closely connected with the 
periosteum on the inner surface of the jaw. It is of the 
size of a chestnut, and on section shows a small cavity in the 
interior. In minute structure it consisted of rounded masses 
of coalescent round or oval epithelium with large nuclei, and 
not of the pavement-cell type. The stroma was not abun- 
dant, and was of a distinctly fibrous nature. The growth 
probably arose in some structure external to the jaw. 

I have recently had under my care a man of sixty-six, 
who noticed some stiffness of the neck for about six months 
before he discovered a tumour near the left angle of the 
jaw. When he came under my care, three months later, 
there was on the left side of the face a new growth in- 
volving the angle and horizontal ramus of the jaw, and 
reaching to the sterno-mastoid behind and the level of the 
thyroid cartilage below. The skin was reddened and ad- 
herent, and at one point had given way. There was no 
ulceration of the mucous membrane of the mouth, and the 
glands in the neck were not enlarged. I isolated the 
growth by a curved incision, including the implicated skin, 
and then sawed through the lower jaw behind the second 
bicuspid tooth, and immediately above the angle. The 
patient vomited persistently after the operation, and sank 
on the seventh day. 

The specimen shows that the lower jaw is surrounded by 
a new growth which clings tightly to tlie periosteum, but 
does not reach up to the edentulous alveolar border. The 
hard bone of the lower border of the jaw is destroyed, and 
the growth penetrates into the cancellous tissue. The sub- 
maxillary gland lying on the inner surface of the mass is 
being gradually absorbed, the growth pressing on its inner 
surface. The surface of the tumour (fig. 176) is surrounded 
by a distinct outline, separating it from the neighbouring 



378 MALIGNANT TUMOURS OF LOWER JAW. 

fat. It appears to have commeuced in the lymph-gland on 
the parotid, for of this there is no trace whatever; the 
remains of the submaxillary salivary gland appear perfectly 
healthy. 

Microscopically the growth proved to be squamous epi- 
thelioma, consisting of the ordinary stroma, through which 

Fig. 176. 




were scattered ordinary squamous epithelial cells with 
" bird's-nest" fairly well marked. It is a little difficult to 
explain this occurrence of squamous epithelioma, since the 
mouth was in no way involved, and so far as could be made 
out there was no primary disease elsewhere. 



379 



CHAPTER XXV. 

DIAGNOSIS AND TREATMENT OF TUMOUES OF THE 
LOWER JAW. 

Diagnosis. — The diagnosis of tumours of tlie lower jaw is 
easier than is the case in the upper jaw. Slowness of growth, 
hardness, and isolation point to a non-malignant tumour, 
and this will be confirmed if there is no tendency to fuugate 
within the mouth, and no enlargement of the neighboiiring 
lymphatic glands. Simple tumours of the lower jaw, if 
allowed to grow unchecked, may after a time burst through 
the skin, and thus give rise to a fungating mass, which, 
however, is of slower growth and more healthy appearance 
than the malignant fungus. Eapidly growing tumours are 
almost invariably cancerous, and the only chance for the 
patient is their early removal, with the portion of bone 
implicated. 

The ijrognosis after removal of tumours of the lower jaw 
is more favourable than elsewhere, since, owing to the 
anatomical relations, it is easy to get rid of the whole 
disease. The question of the return of cancer being in- 
fluenced by removal of one-half of the bone is, as already 
mentioned, still an open one. 

The successful recoveries foUowincr removal of larse 
portions of the lower jaw are very remarkable, operations 
on the lower jaw being as a rule attended by little constitu- 
tional disturbance. Mr. Cusack removed large portions in 
seven cases, with only one fatal result, which was due to 
erysipelas and redema of the glottis. Dupuytren operated 
in twenty cases, with only one death resulting from the 
operation, and that from the same cause as in Mr. Cusack's 
fatal case. The experience of modern surgeons is equally 



380 OPERATIONS ON THE LOWER JAW. 

favourable. When the disease is of ordinary dimensions, 
and the patient is in fair health, the results are exceedingly 
satisfactory. 

0]jeratio7is on the Loiccr Jaw. — Small tumours, involving 
the alveolus, may be removed with bone-forceps without any 
incision through the skin, and even a considerable portion 
of the central part of the lower jaw may be removed with- 
out incising the lip, if the mucous membrane between it 
and the bone be freely divided and the lip drawn well doAvn. 
The large forceps figured at page 245 are particularly useful 
in attacking tumours situated in the molar region without 
external incision, and the gouge and chisel should be freely 
employed for the enucleation of benign tumours in the in- 
terior of the lower jaw. 

The late Mr. Maunder {Medical Times and Gazette, July, 
1874) removed two fibrous tumours of the lower jaw of 
considerable size without any external incision, separating 
the soft parts with a raspatory, and sawing the bone in front 
of and behind the tumour. The principal difficulty in these 
operations was not so much the separation of the tumour as 
its " delivery" through the mouth, which was slightly split 
in one instance. Fortunately the haemorrhage in both cases 
w^as slight and the patients did well, but another surgeon 
who adopted the proceeding was less fortunate, and lost his 
patient by secondary hfemorrhagCj which, considering the 
close proximity of tlie facial artery and the necessary division 
of the inferior dental artery, is not very surprising. For 
my own part, I do not think the extra trouble and risk 
of the proceeding are balanced by the absence of a scar, 
which, in the majority of cases, need not involve the lip, 
and if properly placed will be nearly invisible afterwards. 
The same may be said of the so-called " sub-periosteal re- 
sections" of the lower jaw. In cases of necrosis it is, of 
course, advisable to preserve all the periosteum, and in 
extracting a sequestrum it may be occasionally necessary to 
turn aside soft parts with a raspatory, but any systematic 
stripping of periosteum from a jaw involved in a tumour, 
is not only impossible, but, if undertaken, will surely leave 



OPERATIONS ON THE LOWER JAW. 381 

shreds of periosteum with, possibly, some portion of disease 
attached. 

In order to operate satisfactorily within the mouth it is 
essential that the jaws should be kept fully asunder, and I 
have found nothing so convenient for the purpose as a simpl e 
vulcanite " prop" similar to that used by dentists, placed in 
position on the side opposite to the disease before the adminis- 
tration of chloroform. A string attached to it obviates any 
danger of its being swallowed. The ingenious gag contrived 
for dental operations by Mr. S. J. Hutchinson (fig. 177) 
may also be employed for the same purpose. 

Fig. 177. 




Wlien a large portion of the body and ramus has to be 
removed, a curved incision may be advantageously carried 
along the posterior margin of the tumour, so that the scar 
may be well out of sight afterwards. In this the facial 
artery will be necessarily divided at the anterior border of 
the masseter muscle, and it is advisable to secure both ends 
immediately with ligatures, or the patient may lose a con- 
siderable quantity of blood. The tissues being then dissected 
off the tumour, a careful examination of it should be made 
to see if it be possible to extract the tumour by removing 
the external plate of bone with the gouge and bone-forceps, 
and no harm can come of such an attempt, even if it prove 
abortive, since no vessel of importance is interfered with. 
If necessary, however, a small saw can be applied in front 
of and behind the affected portion, which can then be readily 
isolated and removed. 



382 OPERATIONS ON THE LOWER JAW. 

In making these sections of the lower jaw it is better not 
to complete one before the other is begun, because of the loss 
of resistance consequent upon breaking the continuity of the 
bone ; but both cuts, being carried nearly through the bone 
with the saw, may be conveniently completed together with 
the bone-forceps. 

Wlien the central portion of the lower jaw is removed, it is 
well to take precautionary steps to avoid the possibility of 
the tongue falling back and suffocating the patient. A 
ligature should therefore be passed through the tip of the 
tongue, which will enable a trustworthy assistant to keep it 
drawn forward until the operation is completed. The liga- 
ture should then be attached to one of the hare-lip pins with 
which the wound is closed, and may safely be cut and re- 
moved on the second or third day. In all cases in which 
the inferior dental artery will be divided, the operator 
should be pro\dded with a fine Paquelin's cautery or a small 
plug of wood, which may be thrust into the dental canal 
to stop all bleeding. 

Amputation of one side of the lower jaw can be conve- 
niently performed through an incision running along the 
posterior margin of the bone, from the level of the lobule of 
the ear to the median line, where, if the size of the tumour 
renders it necessary, a vertical incision may be carried through 
the lip (fig. 1 78). The facial artery having been secured, the 
tissues of the cheek and the masseter are dissected up, without 
injuring the flap and without prolonging the incision up- 
wards, by which the facial nerve would be of necessity 
divided. A tooth having been extracted at the point where 
the bone is to be divided, this is effected with a small 
straight-backed saw, and the bone having been grasped with 
the " lion forceps," is drawn forcibly outwards, whilst the 
knife is run along its inner side, care being taken to keep 
close to the bone, so as not to endanger the submaxillary 
gland or lingual nerve. The internal pterygoid muscle 
having been carefully separated from the bone, forcible 
traction is to be made upon the jaw, so as to depress the 
coronoid process, which by a few touches of the knife is 



OPERATIONS ON THE LOWER JAW. 



383 



freed from the fibres of the temporal muscle. The joint 
being now in view, the knife is to be applied to the front of 
it, when the condyle will be at once dislocated, and the 
knife can be carried cautiously behind it, so as to isolate it. 
A forcible wrench of the bone will now tear through the few 
remaining fibres of the external pterygoid muscle, and the 

Fig. 178. 




bone can be removed. At the same time care must be 
taken not to twist the jaw outwards, so as to force the con- 
dyle and neck of the bone against the internal maxillary 
artery, which might thus be torn. 

In order to obviate the difficulty which often occurs at 
this stage of the operation, Dr. Gross recommends a flat 
bone-elevator, to clear the coronoid process and condyle, and 
thus avoid all danger to the artery. Having employed this 
plan on several occasions I can strongly recommend it. 
Mr. Bryant has in some cases dissected up the periosteum 
and slipped the condyle out of it, but there appears to be a 



384 OPERATIONS ON THE LOWER JAW. 

clanger of leaving disease behind in many cases, if this plan 
were generally adopted. 

In the case of small tmnours, removal of one-half of the 
lower jaw is sufficiently easy, but, when the tumour is large, 
it may so completely wedge in the upper part of the bone 
as to hinder the freeing of the coronoid process, and prevent 
dislocation. Under these circumstances the best plan is to 
use the bone-forceps to cut off the coronoid process, or to 
re-apply the saw and cut off the tumour as liigh as may be, 
and subsequently to remove the remaining portion of jaw, 
if the disease is malignant, but not otherwise. Another 
complication is when the tumour breaks away from the 
upper part of the jaw during the operation, thus rendering 
it difficult to dislocate the condyle, owing to the want of 
leverage. The " lion-forceps" of Sir William Fergusson is 
exceedingly useful here, as I have experienced in several 
cases. 

When one-half of the lower jaw has been removed, some 
inconvenience is experienced from the remaining portion 
being drawn inwards by its muscles. To obviate this, Mr. 
Nasmyth, of Edinburgh, originally contrived some metallic 
caps to fit the teeth of the upper and lower jaws, and thus 
keep the bone in position. Mr. Listen speaks highly of 
this apparatus, and a similar contrivance made by Mr. 
Cartwright was of great service in the case of the patient 
of Sir W. Eergusson, whose portrait is shown at page 184. 
I have employed a double vulcanite cap for the teeth for the 
purpose, as being more cleanly, but have found so much 
pain caused by the constant tension of the muscles of the 
unaffected side which are left without opponents, that I have 
abandoned the method altogether, and am content to allow 
the remaining portion of jaw to be thrust inwards, as it 
certainly will be sooner or later. 

In the case of very large tumours, necessitating the re- 
moval of the greater part of the lower jaw, the direction of 
the incision is a matter of considerable importance. Figs. 
179 and 180 show the incision recommended by Sir William 
Fergusson in cases of the kind ; the great advantage being 



VARIETY OF INCISIONS. 



385 



the non-interference with the lip (which is dissected ujd with 
the integuments of the chin), and the fact that the scar is 
completely hidden afterwards. On the other hand, this in- 
cision necessitates the division of both facial arteries, and if 
disarticulation on one side is requisite^ will not afford good 
room for the proceeding without danger to the facial nerve. 
In a case of very large osteo-sarcoma of the lower jaw, already 
described, I preferred an incision through the median line 
of the lip, and was able to dissect the flaps back with great 
ease and rapidity, and to avoid cutting either of the facial 
arteries. The median line is, after all, the best position for a 



Fig. 179. 



Fig. 180. 





. cxr ^^ 



cicatrix, and I regard the division of the lower lip, which 
always readily unites again, as a very unimportant matter. 

The case in which Mr. Syme removed the ramus and 
condyle of the jaw without opening the mouth, through an 
incision in front of the ear, has been already referred to, 
and Professor Hvmiphry adopted a similar incision in the 
case in which he excised the condyle of the lower jaw, which 
will be found in the Association Medical Journal for 1856, 

Whatever the operation which has been performed, care 
should be taken to secure all bleeding vessels, and when 
there are bleeding points deep in the wound which cannot 
thus be treated, the actual cautery should be applied to 
them. The dental artery, necessarily divided in sawing the 

c (" 



386 OPERATIONS ON THE LOWER JAW. 

jaw, is sometimes troublesome if its mouth is not toucliecl 
with the cautery, or the dental canal plugged with a small 
l^iece of wood. The incision in the skin should he carefully 
adjusted with fine wire sutures, and the lip brought together 
with hare-lip pins and a twisted suture, a fine silk suture 
being put in the red mucous-membrane. Care must be 
taken to provide for the drainage of the wound by leaving 
an opening at the most dependent part, into which a drain- 
age tube may be put^ and if necessary a light bandage may 
be applied to support the parts. At the time of the opera- 
tion the wound may be thoroughly sponged out with a 
solution of chloride of zinc (gr. 40 ad 5j), or better, the 
whole of the wound may be thoroughly sprinkled with 
iodoform, which has a most marked antiseptic effect. 

The after-treatment consists in supporting the patient's 
strength by administering fluid nourishment with a feeder 
or tube and bottle, and careful washing out of the mouth 
with detergent washes, so as to keep it clean and healthy 
during the process of healing ; and when the effects of the 
iodoform have worn off, nothing is more effective as an anti- 
septic than the Glycerinum acidi carbolic! freely applied 
with a camel's-hair brush. 

Operations on the lower jaw are cj^uite of modern date. 
Anthony White, of the Westminster Hospital, appears to 
have been the first surgeon who removed a portion of the 
lower jaw (1804). He was followed by Dupuytren (1812), 
Mott and Griife (1821), and Sir P. Crampton in 1824. 
Cusack's celebrated cases of disarticulation occurred imme- 
diately afterwards, and the operation became an established 
one. The names of Liston, Syme, and Fergusson have been 
prominent in connection with the operation in this country, 
whilst abroad Lisfranc, Lallemand, Maisonneuve, Gensoul, 
and other eminent men, have given it their support. 

It has been already noticed how little deformity often 
results from the removal of portions of the lower jaw. Al- 
though the bone is never reproduced, a development of firm 
fibrous tissue takes its place, which affords support to arti- 
ficial teeth, and to which the muscles gain a firm attach- 



ADAPTATION OF ARTIFICIAL TEETH. 387 

ment. In February, 1855, Mr. S]3ence, of Edinburgh, brought 
before the Medico-Chirurgical Society of Edinburgh a pre- 
paration illustrating this point in a marked manner. Eighteen 
years before the patient's death. Sir William Fergusson had 
removed the greater part of the right side of the lower jaw. 
Five years later ]\Ir. Spence had removed the left side of 
the jaw from within half an inch of the symphysis to the 
articulation, and the condition found at death, thirteen years 
after, is thus described {Edinburgh Medical Journal, April, 
1855) : — "A dense fibrous texture connected the small portion 
of the ascending ramus of the right side with the remaining 
portion near the symphysis^ whilst on the left side a similar 
texture occupied the place of the disarticulated bone, on both 
sides affording firm attachments to the masseters and other 
muscles, so that the patient during life had considerable use 
of the mouth." 

The tendency of the muscles to force the remaining portion 
of the jaw out of place has been already referred to. In 
cases in which the central portion of the jaw has been 
removed, the force of the muscles on both sides being equally 
exerted, the rami of the jaw become closely approximated, 
and are united by very firm fibrous tissue. Tliis, of course, 
gives a peculiar narrowness to the lower part of the face, 
which is fortunately concealed in men by wearing a beard. 

The supplying of artificial teeth to a patient who has 
undergone removal of a portion of the lower jaw will tax 
the ingenuity of the dentist considerably, for when the 
muscles have forced the remaining portion out of position, 
it becomes necessary to employ means to bring the parts 
into their normal relation so as to obtain a proper " bite." 
The vulcanite rubber forms a most useful base for the arti- 
ficial teeth, and if firmly attached to the remaining portion 
of jaw it moves very satisfactorily with it, lying in the 
hollow of the cheek and resting upon the dense fibrous 
tissue of the cicatrix. 



CC 3 



388 



CHAPTEE XXVI. 



CLOSUEE OF THE JAWS. 



Spasmodic Closure of the Jaws, which may be of several 
weeks^ duration, is ahnost invariably connected with the 
eruption of the wisdom teeth of the lower jaw. Owing to 
want of room between the second molar and the ramus of 
the jaw, or owing to some malposition of tlie tooth itself, 
the wisdom tooth is unable to assume its normal position, 
and by the pressure which it exerts on the neighbouring 
structures, sets up irritation, which induces a state of tonic 
spasm of the masseter and internal pterygoid muscles. This 
fact has long been known to dental surgeons, and is espe- 
cially alluded to by Mr. Salter in his essay on " Surgical 
Diseases connected with the Teeth" {System of Surgery, 
vol. ii.). 

The accompanying engraving (fig. 181), for which T am 
indebted to Mr. Felix Weiss, shows the condition of parts 

Fig. 181. 




found by him in a gentleman aged forty-three, who suffered 
long and severely from pain and spasmodic closure of the 



CLOSURE OF THE JAWS. 389 

jaws, due to the irritation caused by the wisdom tooth lying 
imbedded horizontally in the alveolus, and pressing against 
the fang of the second molar. It was only after the extrac- 
tion of the second molar that the wisdom tooth was found 
and removed, with complete relief of the symptoms {Trans. 
Odontological Society, 1876). 

In a discussion which took place at the Odontological 
Society, in May, 1861, and is reported in the British 
Journal of Dental Science of the same month, Mr. Tomes 
mentioned a case of retarded eruption of the wisdom tooth 
with closure of the jaws, which had been allowed to go 
unrelieved for more than two years, and was immediately 
cured by the removal of the second molars, so as to allow 
the wisdom teeth to assume their proper position. Mr. 
Coleman, Mr, Mummery, and Mr. Ibbetson narrated on 
the same occasion very similar cases treated in the same 
manner ; and Mr. Drew mentioned a case in which extrac- 
tion of the half-cut wisdom tooth itself gave immediate 
relief. 

The majority of these cases occur about the age of 
twenty, when the eruption of the wisdom tooth is to be ex- 
pected, and the diagnosis is readily made. The treatment 
is obvious. The mouth must be opened by a screw gag, or 
by a spu-al screw wedge of boxwood, under chloroform, and 
either room must be made for the wisdom tooth by extracting 
the second molar, or, if it can be reached, the wisdom tooth 
itself may be removed. 

The impeded eruption of wisdom teeth gives rise to 
various and apparently anomalous symptoms, which are often 
not traced to their true source, such as persistent neuralgia, 
not always referred to the part involved ; but the most 
serious result is the formation of extensive abscesses, which 
burrow extensively about the angle of the jaw and cheek, 
leading to great scarring and permanent deformity. . In a 
yovmg lady, seen by me in consultation some months back, 
the mischief resulting from an impacted wisdom tooth was 
sufficient to put her life in some jeopardy, and has left her 
face permanently scarred by extensive abscesses. 



S90 CLOSURE OF THE JAWS. 

Permanent Closure of the Jaws. — Cases of permanent 
closure of the jaw from cicatrices within the mouth, &c., 
are not of very rare occurrence ; but their description and 
treatment seem to have been very generally neglected by 
modern English authors. Samuel Cooper, in the last edition 
of his " Surgical Dictionary" which he revised, merely refers 
to a case treated by Valentine Mott, who, in 1831, operated 
on a case of sloughing of the cheek, with subsequent closure 
of the jaws, by transplanting a piece of skin (see American 
Journal of Medical Science for Nov. 1831) ; but he enters no ■ 
farther into the treatment. In the new edition of " Cooper's 
Dictionary, 1861, vol. i., the only passage I can find, bearing 
on the question, is the following, under the head of " Cica- 
trization :" — 

" In the mouth, after sloughing of the cheek and gums 
from profuse salivation, the cicatiized surface is so rigid as 
scarcely to allow of the separation of the teeth, but it be- 
comes more pliant in time." This latter statement, however, 
is not borne out by general experience. 

Sir William Fergusson, in the fourth edition of his " Prac- 
tical Surgery," p. 602, says : — 

" The lower jaw occasionally becomes so closely bound to 
the upper, that the teeth cannot be sufficiently separated to 
admit of solid food. This condition may arise from inflam- 
mation and adliesion of the gums, more especially after 
necrosis of the alveolar processes ; sometimes it is the result 
of chronic contraction of a muscle ; occasionally it has been 
accompanied with ankylosis, both here and in otlier joints, 
of which there is a remarkable specimen in the possession of 
M. Dubreuil, of Montpelier, in which, however, a similar 
condition was not present in any other part of the same 
skeleton ; and in certain examples it is difficult to say what 
is the cause. Some years ago I had a patient with the mouth 
thus contracted, and in whom there was a portion of the 
lower jaw in a state of caries : the disease was not in such 
a condition that I could, with propriety, attempt its entire 
removal. A portion of bone, however, was excised, but little 
benefit resulted, and what there was might probably be attri- 



CLOSURE OF THE JAWS. 391 

buted more to the use of a screw-dilator than to the partial 
removal of what I considered a source of irritation. Mott 
has succeeded, in two instances, in relieving such permanent 
adstrictions ; and in the first volume of the Provincial 
Medical and Surgical Journcd there is a case recorded 
wherein I was fortunate enough to produce a similar effect, 
by dividing the masseter on one side with a narrow knife, 
passed from the mouth between that muscle and the skin. 
If ankylosis be the cause of closure, it is doubtful if the sur- 
geon would be justified in interfering. In the course of my 
experience I have seen many instances of the kind above 
referred to, but feel bound to state that most of my attempts 
at improvement have utterly failed." 

By far the most complete account of this affection is 
given by Dr. Samuel G-ross, of Philadelphia, in his large work 
on surgery, from which I take the following quotation : — 

" Ankylosis, or Immohility of the Jaiv. — Tliis distressing 
affection, which may be produced in a variety of ways, may 
exist in such a degree as to render the patient entirely unable 
to open his mouth, or to masticate his food. 

" The most common cause, according to my observation, 
is profuse ptyalism, followed by gangrene of the cheeks, lips, 
and jaw, and the formation of firm, dense, unyielding, ino- 
dular tissue, by which the lower jaw is closely and tightly 
pressed against the upper. Such an occurrence used to be 
extremely frequent in our south-western States during the 
prevalence of the calomel practice, as it was termed, but is 
now, fortunately, rapidly diminishing. 

" Children of a delicate, strumous constitution, worn out 
by the conjoint influence of mercury and scarlatina, measles, 
or typhoid fever, are its most common victims ; but I have 
also seen many cases of it in adults and elderly subjects. 
In the worst cases there is always extensive perforation of 
the cheeks, permitting a constant escape of the saliva, and 
inducing the most disgusting disfigurement. 

" Secondly, the affection may depend upon ankylosis of 
the temporo-maxillary joints, in consequence of injury, as a 
severe sprain or concussion, or arthritic inflammation, lead- 



392 CLOSURE OF THE JAWS. 

ing to a deposition of plastic matter, and the conversion of 
this substance into celhilo-fibrous, cartilaginous, or osseous 
tissue. I have met with quite a number of such cases, 
several in very young subjects. 

" Thirdly, the immobility is occasioned by a kind of 
osseous bridge, extending from the lower to the upper jaw, 
or from the lower jaw to the temporal bone; such an 
occurrence, however, is not common, and is chiefly met 
with in persons who have suffered from chronic articular 
arthritis. 

"Finally, immobility of the jaw may be caused by the 
pressure of a neighbouring tumour, especially if it occupies 
the parotid region, so as to make a direct impression upon 
the temporo-maxillary joint. 

" However induced, the effect is not only inconvenient, 
seriously interfering with mastication and articulation, but 
it is often followed, esjDccially if it occur early in life, by a 
stunted des'elopment of the jaw, exliibiting itself in marked 
shortening of the chin, and in an oblique direction of the 
front teeth. 

" 'V^^len complicated with perforation of the cheek and 
destruction of the lips, the jDatient has little or no control 
over his saliva, and is so terribly deformed as to render him 
an object at once of the deepest disgust and the warmest 
sympathy. 

" The treatment of this affection must depend upon the 
nature and situation of the exciting cause. When the 
difficulty is in the joint, occasioned by the formation of 
cellulo-fibrous adhesions, the only thing that can be done is 
to break up the adhesions, upon the same principle as in 
ankylosis of any other joints. For that purpose — the patient 
being thoroughly under the influence of chloroform — the jaw 
is forcibly depressed, either by a M-edge made of cedar-wood, 
or by an instrument constructed on the lever-and-screw 
principle, and figured by Scultetus in his ' Armamentarium 
Chirurgicum.' 

" When the immobility depends upon the presence of 
inodular tissue, the proper remedy is excision of the offending 



CLOSURE OF THE JAWS. 393 

substance — an operation wliicli is both tedious, painful, and 
bloody, and, unfortunately, not often followed by any but 
the most transient relief, owing to the tendency in the parts 
to reproduce the adhesions, however carefully and thoroughly 
they may have been removed. There is the same remark- 
able disposition in these cases to the contraction and re- 
generation of the inodular tissue, as in the case of burns 
and scalds. 

" During my residence in Kentucky I had a large share 
of such cases ; and, although I never failed to make the 
most thorough work — not unfrequently repeating the opera- 
tion several times at intervals of a few months — it is my 
duty to state that few of them were permanently relieved. 
After the excision is effected, the patient must make constant 
use of the wedge, wearing it for months and years, so as to 
counteract the tendency to reclosure. 

" Immobility of the jaw, caused by the formation of an 
osseous bridge, might possibly be remedied by the removal 
of the adventitious substance by means of the saw and pliers. 
The great difficulty, however, in such an event, is the 
obscurity of the diagnosis." 

I must now refer to an essay by Dr. Frederic Esmarch, 
Professor of Surgery in the University of Kiel, on " The 
Treatment of Closure of the Jaws from Cicatrices,"^ in 
which he investigates the pathology of the affection, and 
describes an operation for its relief by the formation of an 
artificial joint in the lower jaw — an operation which has 
given most satisfactory results in cases under my own 
treatment. 

Professor Esmarch says : 

" Injuries to the mucous membrane of the cheek damage 
the mobility of the lower jaw in a greater or lesser degree 
by their cicatrisation, as is well known. 

" The cause of this ankylosis of the lower jaw is often 
thought to be a growing together of the inner surface of the 
cheek with the bones or gums ; this is not a correct view, 

* "Die Behandlung der narbigen Kieferklemme durch Bilduug eiues 
kiinstlichen Gelenkes iim Unterkiefer." Kiel, 1860. 



394 CLOSURE OF THE JAWS. 

however, and has, in many cases, led to improper treatment. 
In order to clear up this error it is necessary to examine the 
conditions which, in health, make movements of the lower 
jaw within the mouth possible. The cavity of the mouth is 
divided by the alveoli and teeth into an inner and outer 
space ; the latter is closed in front by the cheeks and lips, 
which form an elastic dilatable sac ; within this the rows of 
teeth can be separated from each other, even witli the lips 
shutj and much further when the mouth is opened. The 
inner surface of this sac is covered by a mucous membrane 
whicli is also very dilatable and elastic, and which forms a 
duplicature at the upper and lower boundaries of the outer 
cavity of the mouth, where it is reflected on to the outer 
surface of the bone, and ends on the edges of the alveolus 
as gum. This membrane is so elastic that when the mouth 
is open to its widest extent it is still by no means put on 
the stretch ; whilst, when the mouth is closed, it presents 
no folds. 

" It is clear that as soon as this dilatable sac shrinks 
together, loses its elasticity, or is replaced by a rigid sub- 
stance, the mobility of the jaw must either be injm^ed or 
entirely cease. This happens most frequently through the 
formation of cicatrices which follow ulceration or sloughing 
of the mucous membrane of the mouth, as from mercurial 
stomatitis or noma. 

" The occurrence of what we call secondary cicatrix- 
atrophy, or cicatrix-contraction, is sufficiently well known. 
As soon as the cure commences, the movable parts of the 
neighbourhood, so far as they can be, are drawn by the 
shrinking of the newly formed tissue towards the cicatrising 
spot; slowly, it is true, but with almost irresistible 
power. 

" If there are no parts in the neighbourhood which can be 
drawn together to repair the loss of substance, there neces- 
sarily follows a cicatrisation of the surface ; but the cicatrix 
remains thin, tender, and stretched to a great extent for 
some time at least after its formation ; it is only after it has 
existed for a long time that it assumes a more ductile con- 



CLOSURE OF THE JAWS. 395 

dition, so as to become something more like the uatufal skin 
or mucous membrane. 

" If, therefore, the mucous membrane of the cheek be com- 
pletely destroyed from one alveolus to the other, on both, or 
merely on one side, the resulting cicatrix must necessarily 
tend to press the jaws more and more closely against one 
another, the depressor muscles of the lower jaw being quite 
incapable, as experience has shown, of preventing the con- 
traction of the cicatrix. When cicatrisation is complete, the 
elastic ductile mucous sac of the cheek is found to have dis- 
appeared, and instead of it the cicatrix tissue stretches so 
tightly from one alveolar edge to the other, that it is scarcely 
possible to put the finger between it and the rows of teeth ; 
and the teeth themselves can be separated only a little, if at 
all, or only shifted from side to side very slightly. 

"Just the same immobility of the lower jaw follows 
cicatrisation after sloughing involving the whole thickness 
of the cheek, although here the opening of the mouth is 
widened as far as the anterior edge of the masseter muscle, 
or still farther ; and in this case, too, the cheek sac is entirely 
destroyed. In these cases it is the quasi Hp or posterior 
margin of the gap which stretches tightly from one jaw to 
the other. If, in such cases, one is successful in covering 
the loss of substance by dividing the skin, or by transplanta- 
tion of a flap, the cicatrisation of the inner surface of the 
flap (being uncovered by mucous membrane) necessarily has 
the effect of increasing the immobility of the lower jaw. 

" As far as is known there are few or no means available 
to check the shrinking of cicatrices. It is one of Dieffenbach's 
great services to surgery that he gave this theory its full 
value ; it was he who first taught us to place a proper value 
upon this action of Nature, and showed how to make it 
available for operative proceedures under certain circum- 
stances. Thus, he first taught how to cure the closure of 
the mouth by covering the margin with mucous membrane ; 
to form eyelids which do not adhere to the globe or roll 
inwards after cicatrisation ; and many other methods which 
we now consider self-evident in plastic surgery. 



396 CLOSURE OF THE JAWS. 

" Also, for tlie treatment of the worst cases of cicatrised 
contracted jaw, Dieffenbach has given the most rational 
advice when he suggests, after the separation of the cicatrix 
from the bones, to lay over the surface of the wound a sound 
flap of mucous membrane. Unfortunately, in most cases, 
this cannot be done, because, just in the neighbourhood of 
the cicatrix, it is impossible to find more healthy mucous 
membrane. Instead of the mucous membrane one can 
undoubtedly do as Jaesche did {Med. Zcituncj Eiisslands, xxvii. 
1858), viz., make use of a flap of skin for a lining; still it is 
difficult in many cases to get such a flap from the immediate 
neighbourhood. I would not hesitate, however, in desperate 
cases — as, for instance, where there is a great deficiency on 
both sides — to take a flap from the skin of the arm. 

" All the hitherto received methods, such as the freeing 
or cutting through of the cicatrix from the mouth — the 
separation of the whole cheek, in order to accomplish tliis 
perfectly — the extirpation of the mass of cicatrix — the ap- 
plication of mechanical apparatus in order to drag the jaws 
asunder by degrees, &c. &c., can only be of avail in those 
cases where, in some angle or other, there is found a remnant 
of mucous membrane. If one succeeds after separation of 
the cicatrix, in preventing, by the appKcation of mechanical 
means for a long time, the cicatrisation in the undesirable 
direction, the contraction will take place in another direction, 
and by degrees will drag the remnant of mucous membrane 
up to the skin. In every case it takes years before such 
methods can be properly estimated ; for, as far as is known, 
the secondary shrinking of a cicatrix takes place very late, 
even after complete or sufficient healing over has occuiTed. 
Putting aside the more favourable cases, there still remains 
a number of patients of this kind, in whom the usual methods 
produce no lasting cure, just because there is no more old 
mucous membrane left ; and for these cases I recommend 
the formation of an artificial joint in front of the contraction, 
in order to give, at least, the other half of the jaw some, 
although a limited, motion, and so to lessen considerably the 
sufferings of these unfortunate patients. 



CLOSURE OF THE JAWS. 397 

" The formation of an artificial joint in the ramus of the 
jaw has ah-eady been recommended and tried by Dieffenbach 
(' Operative Chirurgie,' i. 435), but behind the contraction, 
and naturally without any good result, since the impediment 
to motion lies more forward, and thus is not removed. Von 
Briins has also operated in this manner without success.'' 

This proposal of Professor Esmarch to form a false joint 
in front of the cicatrix was suggested to him by a case which 
came under his care in 1854<, in which considerable destruc- 
tion of the cheek and contraction of the cicatrix had oc- 
curred, together with immobility of the lower jaw and 
necrosis of a portion of it. The necrosed portion was for- 
tunately in front of the cicatrix. The bone having been 
removed, it was found that mobility was restored, and a 
useful amount of movement obtained. Professor Esmarch 
therefore suggested, at the Congress of Gottingen, in 1855, 
the removal of a piece of bone in cases of contracted cicatrix; 
but did not happen to meet with a case suitable for the 
operation until after it had been successfully performed by 
Dr. Wilms, of Berlin, in 1858_, shortly after which he himself 
operated upon a case at Kiel, and with the best results. The 
operation was subsequently performed by Dittl, of Vienna 
(Ocst. Zeitsclirift fur praktische Hcilkunde, vol. v. p. 43, 
Vienna, 1859) ; and by Wagner, of Konigsberg {Annali di 
Medicina di Kocnigsbcrg, vol. ii. p. 100, 1859). 

Shortly after this proposal of Esmarch, it would appear 
that Professor Eizzoli, of Bologna, quite independently con- 
ceived a somewhat similar idea, but modified the proceeding 
by merely cutting through the jaw, without removing any 
portion of bone. He operated in this way first in 1857^ and 
subsequently had three other successful cases. In Ptizzoli's 
cases no external incision appears to have been made, but 
the section was accomplished from the mouth with powerful 
forceps. This proceeding has been followed by Professor 
Esterle, from whose essay in the Annali Universali di 
Medicina (Omodei, vol. clxxvi.), I have extracted these 
particulars. 

Esmarch's operation appears to me to possess a decided 



398 CLOSURE OF THE JAWS. 

advantage over that of Eizzoli, in the fact that a piece of 
bone is removed, by which the formation of a false joint is 
facilitated, as we know by experience in cases of resection of 
the elbow, &c. ; and the external incision can never be a 
matter of any importance, whilst it admits of the application 
of the saw, and so avoids risk of splintering the bone. 

Mr. Mitchell Henry was, I believe, the first surgeon to 
put Esmarch's operation into practice in this country, he 
having performed it a few weeks before myself. The patient 
was a female, on whom a variety of operations had been 
performed (among others, division of the masseter), and 
whom I had had under my own care at the St. George's and 
St. James's Dispensary, two years before, when I divided 
the cicatrices freely and screwed the mouth open, but with- 
out permanent benefit. Mr. Henry employed the chain 
saw, and removed about half an inch of bone. The patient, 
unfortunately, sank a few days afterwards, apparently from 
pytemia and exhaustion. In my own cases I used an ordi- 
nary narrow saw, in preference to the chain, and was enabled 
to remove sufficient bone to give free movement, through a 
small incision along the edge of the jaw. 

The subject of the contraction of cicatrices in the mouth, 
and their treatment, though it has attracted little notice 
among British authors, in Paris, on the contrary, has 
excited much attention, and has furnished the topic of 
frequent discussions at the Soci^t^ de Chirurgie. Since the 
date of the publication of a paper upon the subject by 
M. Verneuil (Archives G4nerales, 1860), several operations 
have been performed by French surgeons, but apparently 
with but little success, since in cases operated on both by 
the method of Esmarch and of Eizzoli reunion of the 
divided jaw has taken place. 

Thus, on the 4th of February, 1863, M. Boinet brought 
before the Society a little girl on whom he had previously 
performed what he terms Esmarch's operation (but which 
appears to have consisted in the simple division of the jaw, 
recommended by Eizzoli, and not the removal of a wedge 
of bone, as originally proposed by Esmarch), and in whom 



CLOSURE OF THE JAWS. 399 

the bone had reunited. M. Deguise thereupon quoted a 
case in which he had removed a centimetre and a half of 
bone with the same unsatisfactory result, and expressed a 
doubt whether a single successful case could be produced. 
On the 11th of February, 1863, M. Deguise brought the case 
he had alluded to before the Society, and showed that the 
failure " depended upon the formation of an osseous callus 
at the level of the resected portion." At the same meeting 
M. Bauchet showed a young Syrian girl in whom contrac- 
tion of the left side had taken place, together with a loss of 
substance of the cheek and commissure of the lips, equalling 
a five-franc piece in size. In this case a centimetre and a 
half of the jaw was removed ; and though extensive suppu- 
ration and necrosis of the jaw ensued, the girl made a good 
recovery, and at that date (February 4) a very satisfactory 
amount of movement and power of mastication had been 
obtained. 

On the 29th of July, 1863, M. Verneuil communicated to 
the Societe de Chirurgie the histories of several cases ope- 
rated upon by M. Eizzoli himself, the results of which were 
most satisfactory. In the first the operation (simple division 
of the jaw from within the mouth) was performed in 1857, 
and after six years the boy was able to eat solid food most 
satisfactorily ; the second case, operated upon in the same 
year, was equally good. In the third case, operated upon in 
1858, the mouth could not be widely opened, and the child 
had some difficulty in speaking. The fourth case, operated 
upon in 1860, was most satisfactory. M. Verneuil also 
mentioned a fatal case which occurred in M. Eizzoli's prac- 
tice, and alluded to my paper in the Dublin Qvxirterly Journal 
of May, 1863. 

It would appear that M. Eizzoli had adopted the plan of 
inserting a foreign body, such as a piece of gutta-percha, 
between the cut surfaces of bone, with the view of preventing 
their reunion, and the possibility of doing this was roundly 
denied by one of the speakers at the Society de Chirurgie. 
There appears to me, however, to be no difficulty in effecting 
this, provided the section be made from within the mouth 



400 CLOSURE OF THE JAWS. 

and without external incision, as proposed by M. Eizzoli, but 
I cannot speak with certainty, having no experience of his 
operation. 

One observation of M. Verneuil's is, I think, worthy of 
special notice — viz., that all liizzoli's successful cases have 
been examples of contraction within the mouth witliout loss 
of substance of the cheek, whereas the unsuccessful cases of 
the operation which have occurred in Paris had suffered 
considerable damage in the soft tissues ; and he suggests 
that in these cases Esmarch's operation may be more properly 
applicable. In one of my cases the loss of substance in 
the cheek had been replaced by a dense cicatrix, which it 
would have been unwise to interfere with from within the 
mouth, and at the same time, owing to its firm contraction, 
it would have been impossible to have performed Eizzoli's 
operation in the way he recommends — viz., without any 
external incision. 1 thei'efore resorted to Esmarch's pro- 
ceeding, with the results of which I have every reason to be 
satisfied. 

The first case in which I performed Esmarch's operation 
was in a boy aged fifteen, who was sent to me by Mr. 
Martin, of Portsmouth, in 1862, with complete closure of 
the jaws, the result of the contraction of cicatrices within 
the mouth following extensive necrosis. The cicatrices had 
been divided, and his mouth screwed open in 1856, but 
witliout permanent benefit, and he obtained his food by 
rubbing it between his teeth, or by putting it through an 
aperture between the teeth on the right side. The mouth 
was firmly closed, the teeth overlapping ; there was a cica- 
trix at the right angle of the mouth, and a dense band could 
be felt within the mouth on the same side. Fig. 182 shows 
his condition on admission. I made an incision two inches 
long upon the lower border of the jaw, in front of the right 
masseter, and removed a wedge of bone measuring rather 
more than a quarter of an inch along the upper, and half an 
inch along the lower border. The piece contained the 
mental foramen. The mouth could now be freely opened, 
and the boy was discharged at the end of a month able to 



CLOSURE OF THE JAWS. 



401 



open his mouth, as seen in fig. 183 ; the distance between 
the teeth beino- seven-eiohths of an inch. 



Fig. 182. 



Fig. 183. 




The second case in which I operated in tlie same manner 
was complicated by the presence of a dense cicatrix, occupy- 
ing nearly the whole of the cheek of the affected side. The 
angle of the mouth had also given way during a recent 
attack of fever, and the patient presented the unsightly ap- 
pearance shown in fig. 184. The patient was twenty-three 
years old, and the sloughing and contraction occurred at the 
age of six. She was sent to me by Mr. Bullen, of the 
Lambeth Infirmary, in January, 1864. I made an incision 
along the border of tlie jaw, and, as in the former case, re- 
moved a wedge of bone measuring seven-eighths of an inch 
along its lower border. This also contained the mental 
foramen. The patient's mouth could now be opened to the 
extent of half an inch. I made two subsequent attempts to 
remove the deformity of the cheek by plastic operations, 
but only succeeded in restoring the commissure of the lips, 
the vitality of the cicatricial tissue being too low to admit 
of its uniting with other tissues. At the time of her dis- 

D D 



402 



CLOSURE OF THE JAWS. 



charge the commissure of the lip was half an inch in 
breadtli ; and with a piece of black plaster over the opening 
which was left behind it, the patient was very comfortable. 



FiCx. 184. 



Fig. 185. 




Fig. 185 shows her condition at this time with the mouth 
open. 

With regard to the permanency of the relief afforded in 
these cases, I may mention that Barton B,, the boy on 
whom I operated in July, 1862, continued in perfect health, 
and able to take plenty of nourishment, although the move- 
ments of the jaw had very decidedly diminished, owing 
apparently, to contraction of the fibrous tissues around the 
new joint, due, as the patient and his mother believe, in the 
first instance, to the cold of the severe winter following the 
operation, from which he suffered considerably. 

In March, 1865, I had the boy up from the country, and 
found that the space between the left molar teeth had 
diminished from seven-eii>hths to one-eiohth of an inch, and 
that between the left lateral incisors from five-ei"hths to 
two-eighths of an inch. The movement was still free enough 
to show that osseous ankylosis had not taken place in 



CLOSURE OF THE JAWS. 403 

the uew joint ; but whether the contraction was due 
simply to changes at that point or to the contraction of 
some band it was impossible to determine, as the boy 
positively refused all interference, either with or without 
chloroform. 

In this case, however, I believe that I was not sufficiently 
careful to make the section of the bone entirely in front of 
the cicatrices, a point I bore in mind in the second opera- 
tion. 

The second patient, Ellen Johnson, is in perfect health, 
and has good use of her jaw. I saw her at Plymouth in 
August, 1866, and have heard since that she continues per- 
fectly well. She called on me in July, 1880, in good health 
and with perfect movement of the joint. The opening in 
the cheek remained the same. 

Mr. Bernard, of Clifton, performed Esmarch's operation 
with the greatest success, upon a young man of twenty- one, 
in January, 1865. The case was one of great destruction 
of the cheek by sloughing, and the alveoli of the upper and 
lower jaw projected considerably through the aperture thus 
left. Mr. Bernard cut away the alveoli, and then removed 
a wedge from the lower jaw in front of the contraction with 
the most satisfactory results. 

In the Mcdicrd Times and Gazette, 1876, will be found 
cases of Esmarch's operation performed successfully at St. 
Thomas's Hospital by Sir W. MacCormac and Mr. Francis 
Mason ; at the Middlesex Hospital, by Mr. Lawson ; and at 
the Hotel Dieu, Paris, by M. Ptichet. In 1883 I again per- 
formed the operation in University College Hospital, on a 
woman, aged thirty-two, who was kicked by a horse on the 
right side of the face when eleven years of age, since which 
she had had more or less closure of the jaws. The teeth 
were firmly closed, the lower incisors being forced outwards. 
It was clearly a case of ankylosis of the temporo-maxillary 
articulation, and I should have preferred to operate in that 
region, but for the patient's anxiety to be relieved as soon 
as possible in order to return to her family. She recovered 
with good use of the jaw. 

D D 2 



404 CLOSURE OF THE JAWS. 

In connection with this subject, and to show the patholo- 
gical result of the proceeding, I may refer to the following 
account of the post-mortem examination of a case of 
Esmarch's operation, read before the Societe Imperiale de 
Cliirurgie, September 5, 1866. 

M. Boiuet showed the lower jaw of a girl who had closure 
of the jaws from cicatrices resulting from cancrum oris. 
Eizzoli's operation had been performed at the beginning of 
1860, but failed at the end of twelve months. In 1863 a 
wedge was removed with perfect success. She died of 
phthisis in 1866. 

" The right ramus of the jaw is deformed, being shorter 
and broader than on the opposite side. The condyle and the 
coronoid process are less separated and shorter than on the 
left side, and the sigmoid notch is shallower. The left tem- 
pore -maxillary articulation has lost much of its mobility, 
and the ligaments are shortened. The sections had been 
made in the middle of the body of the bone, the angle being 
intact. The lower border of the jaw presents a difference 
in length of IJ centimetre between the two sides, which cor- 
responds to the breadth of the wedge of bone removed at 
the operation. The osseous tissue of the ascending ramus 
appeared reddened, the dental nerve was natural at its entry 
into the inferior dental foramen. Between the two portions 
of the jaw there exists a very complete false joint, which is 
permanent three years after the operation ; it is very mobile, 
and the parts which serve as the hinge are fibrous and 
stretched so that the middle portion of the jaw can fall ; 
during life this was sufficient to allow easily the introduction 
of the forefino'er into the mouth. The fibrous tissue which 
unites the bones occupies the whole interval left between the 
bones, and extends for the whole depth of the jaw. Its 
breadth appears to be quite a demi-centimetre, and its 
strength uniform." — Gazette HcMomadaire, October 12, 
1866. 

In a few cases of bilateral ankylosis it has been thought 
advisable to perform Esmarch's operation on both sides of 
the jaw. Thus Dr. Maas, of Breslau, relates in the Archiv 



CLOSURE OF THE JAWS. 405 

filr Klin. Chirurg. (Band xiii. Heft 3) the case of a man, 
aged twenty- seven, who was admitted into hospital with 
ankylosis of the jaw on both sides. It had come on after 
an attack of scarlet fever when he was seven years old, 
being preceded by severe pain in the part ; and since the 
age of ten he had not been able to move the jaw at all. The 
secondary dentition was attended with great difficulty in the 
removal of the milk teeth ; and the new teeth were irregu- 
larly developed, and for the most part were displaced late- 
rally. The patient, on admission, was of ameniic appearance, 
though in moderately good condition ; the lower jaw was 
imperfectly developed. Speech was somewhat muffled, but 
was quite intelligible. Not the least movement of the jaw 
could be produced under anaesthesia. Herr Middeldorpf 
operated on the right side, removing a wedge-shaped piece 
of bone, as recommended by Esmarch, near the angle. The 
result of this was the formation of a false joint, with power 
of opening the mouth passively to the extent of about an 
inch. Between four and five months later. Dr. Fischer per- 
formed a similar operation on the left side ; four months 
after this the patient could voluntarily open his mouth 
without pain to the extent of about an inch and a quarter, 
and his general condition was much improved. 

The treatment of cicatricial contraction within the mouth 
by simple division has been proved over and over again to be 
perfectly useless ; but when suitable apparatus is adapted 
to the jaws, so as to prevent re-contraction, a very good 
result may, with patience, be produced in cases uncomplicated 
by destruction of the cheek itself. 

Fig. 186 shows a sketch of the mouth of a woman who 
had cicatricial bands on each side, binding the cheeks and 
gums together so that she was able only to separate the lips, 
and in whom division of the cicatrices had been practised in 
childhood. The lower jaw was edentulous, but the upper 
front teeth remained, and Mr. Felix Weiss succeeded in 
adapting a small lower denture so as to antagonize the 
upper teeth and prevent the further contraction which ap- 
peared imminent, at the same time greatly improving the 



406 



CLOSURE OF THE JAWS. 



patient's power of articulation {British Journal of Dental 
Science, May, 1880). 



Fig. 186. 




The great drawback to treatment by division of bands, 
and one with regard to which it contrasts unfavourably with 
Esmarch's proceeding, is the amount of pain which the patient 
must, of necessity, undergo during tlie after-treatment. It 
requires no small amount of courage on the part of the patient, 
and some determination on the part of the attendant, to carry 
out the necessary manipulations within the mouth, more par- 
ticularly during the first few days after the operation ; and 
even after the shields are fitted to the mouth they cause 
some pain and inconvenience, which only those who have 
arrived at years of discretion will submit to. 

Fig. 187 shows the form of the silver " shields" adapted 
to the upper and lower jaws by the late Mr. Clendon, formerly 
dental surgeon to the Westminster Hospital, in a case of Mr. 
Barnard Holt's. The patient was a girl of seventeen, and 
was under Mr. Holt's care in 1862, having five years before 
had fever, with an abscess of the cheek on the right side, 
which led to such contraction and adhesion of the mucous 
membrane to the jaw as to cause great difficulty in opening 



CLOSURE OF THE JAWS. 



407 



the mouth. Some attempts had been made to open her 
mouth by the screw, &c., and in 1860 Mr. Holt divided some 
of the cicatrix with temporary benefit. Mr. Holt now divided 



Fk;. 187. 




the cicatrix within the cheek freely under chloroform, and 
encountered a firm plate of bone extending between the 
alveoli of the two jaws, which necessitated the use of a saw 
for its division. Mr. Clendon subsequently fitted the above- 
mentioned shields to the teeth, and wedges were gradually 

Fig. 188. 




introduced between them to separate the jaws. This treat- 
ment was continued for three months, when she was able to 
open the mouth to the full extent, as seen in fig. 188. 



408 CLOSURE OF THE JAWS. 

The effect of tlie use of the shields seems to have been, 
not merely to prevent adhesions between the inside of the 
cheek and the alveolus, 1 jut to re-establish, to a great extent, 
the sulcus of mucous membrane at the base of the alveolus, 
upon which so much stress is laid by Professor Esmarch. 
Surgical experience in cases of ruptured perineum, &c,, sliows 
how soon mucous membrane is reproduced where it has once 
existed, or even appears on adjacent parts where its presence 
gives rise to inconvenience ; and there can be no question 
that in this case the mucous lining of the cheek has been 
reproduced to a great extent, and particularly near the lower 
alveolus. Esmarch's theory, that there must be some portion 
of old mucous membrane remaining which afterwards be- 
comes stretched, is certainly untenable as regards this case 
at least, for without doubt the whole lining of the cheek 
and the outside of the alveoli were perfectly raw, owing to 
the division of the firm cicatrices. 

The cause of non-success in former attempts at mechanical 
appliances is to be found, I think, in the fact that they have 
all been directed simply to keeping the jaws apart, without 
any reference to the re- establishment of the mucous lining 
of the cheek, upon which, as Professor Esmarch says, the 
movements of the jaw so much depend. That the success 
in the foregoing case depended upon this is proved, I think, by 
the existence of a firm band in the cheek which would effec- 
tually control all movement were its extremities attached to 
the two alveoli ; but as it is, it gives no inconvenience, and 
will, in all probability, atrophy in the course of time. 

At the Odontological Society, in June, 1864, Mr. Cart^ 
Wright narrated a very similar case of contraction (with the 
exception that there was no bony bridge between the alveoli), 
in a woman, aged thirty-eight, which he successfully treated 
by similar means, using wedges of vulcanized india-rubber 
affixed to the shields to obtain the necessary distension. 

The occurrence of an osseous lamella or bridge between 
the two jaws is a rare but not unique occurrence. In the 
Medical Gazette, of July 4, 1845, Mr. J. G. French has 
reported and figured an excellent example of ankylosis pro- 



CLOSURE OF THE JAWS. 409 

duced by a bridge of bone, which occurred under his care 
at the St. James's Infirmary. 

The patient was twenty-two at the time of his death, and 
the closure of the jaws dated from infancy. He was fed 
through an aperture made by the removal of the incisors on 
the left side. At tlie age of fourteen an o^^eration for his 
benefit had been undertaken by an eminent surgeon, and 
incisions in the mouth had been made with this object, but 
without any good result. On post-mortem examination the 
jaws were perfectly united on the left side, and only the 
smallest degree of motion was possible on the right ; the 
soft parts were removed and the base of the skull was mace- 
rated, when ankylosis was discovered to exist between the 
upper and lower jaws on the left side, the ramus of the in- 
ferior maxilla, immediately internal to the mental foramen, 
extending upwards by a broad thin plate, and uniting with 
a corresponding plate of the superior maxilla, a cartilaginous 
material forming the bond of union. The articulation of 
the jaw was normal. 

Mr. Trueman also mentioned in the discussion whicli 
followed the narration of Mr. Cartwright's case {British 
Journal of Dental Science, June, 1864) that he remembered 
seeing in the Museum at Berlin a very curious case where 
cicatrices existed on both sides of the mouth, which were 
completely ossified, so that the preparation showed the two 
jaws united by filaments of bone, on either side of the jaw 
externally. 

Subsequently to Mr. Holt's case, I had under my care a 
patient with a very severe form of contraction — viz., on both 
sides of the mouth. The patient was eighteen, and the 
contraction dated from her fifth year, when she had fever. 
Various attempts had been made to give her relief by 
dividing the cicatrices and using wedges, &c., without 
benefit ; and when she came under my care she had no 
power of separating the jaws at all, and the cheeks were 
firmly attached to the alveoli from the angles of the mouth. 
Having secured Mr. Clendon's co-operation, I freely divided 
the cicatrices^ and after repeated trials that gentleman sue- 



410 CLOSURE OF THE JAWS. 

ceeded in fitting in shields resembling those used in Mr. 
Holt's case, but reaching over both sides. It was found 
necessary to extract all the teeth, and after more than three 
months' assiduous care and frequent modification of the 
shields, the patient being constantly placed under the influ- 
ence of chloroform for the purpose, a very satisfactory result 
was obtained, there being exactly one inch between the 
metal shields in the incisive region, which would have left 
about half an inch if the teeth had been in situ. 

In order to contrast the permanent results of this method 
of treatment with that by removal of a portion of the 
jaw, I may mention that three years after the opera- 
tions, I ascertained the following facts respecting these 
patients : — 

Frances H., the girl treated by JMr. Holt by internal 
division and the application of metal shields, wore the shields 
for some months after leaving the hospital, but discontinued 
them after some eighteen months. The contraction had 
returned to some extent, the band which existed in the 
cheek having shortened so as to diminish the extent to 
which she could separate the teeth one-half — viz., from 
three- fourths to three-eighths of an inch. The cheek was 
slightly tucked in owing to the contraction ; but the girl 
was perfectly well and comfortable, and would not allow 
any interference with the j^arts. 

Isabella M'Nab (my patient treated by metal shields), 
whose case was remarkable owing to the adhesions being 
present on both sides of the mouth, was seen by l)r Crockett, 
of Dundee, in the middle of 1864, and that gentleman has 
kindly sent me the following report of her condition : — 
" The jaws can be opeued with ease to the extent of half an 
inch ; she has begun to articulate distinctly within the last 
two months, and witliin tlie last fortnight is able to chew a 
crust of bread, having some lateral motion of the jaw. A 
fetid muco-purulent discharge continues to come from the 
mouth, but her general health is much improved." 

Having thus shown that cases of closure of the jaws by 
cicatrices are amenal :)le to two modes of treatment with most 



CLOSURE OF THE JAWS. 411 

satisfactory results, and having had personal experience in 
carrying out both methods, I shall venture to draw a brief 
comparison between them. 

Esmarcli's operation is a comparatively easy proceeding ; 
and in cases where only one side of the jaw is affected, 
restores the patient a very useful, though one-sided, amount 
of masticatory power in two or three weeks, and with very 
little suffering or annoyance. One side of the jaw is, how- 
ever, rendered permanently useless (its previous condition), 
and there is a necessarily resulting deformity, which is not 
however, of a very distressing character. The paralysis, from 
the division of the nerve, is so slight as not to be worthy 
of mention. 

The treatment by internal division and the use of metal 
shields, is applicable to all cases in which the entire thick- 
ness of the cheek is not involved, and can, with due care 
and attention, be made to yield most satisfactory results — 
the patient enjoying the full use of both sides of the jaw, 
and having no deformity or loss of sensation. On the other 
hand, the operation itself is difficult and bloody, and the 
after-treatment is tedious and troublesome ; and it is essential 
for success to have the co-operation of a dental practitioner 
fully conversant with the frequent modifications which the 
metal shields must necessarily undergo. The age of the 
patient is an important element also, since it would be im- 
possible, I imagine, to carry out the treatment with any 
hope of success, unless the patient were of an age to assist, 
or at least not to resist, the surgeon. In my own case 
chloroform was resorted to on every occasion of real opera- 
tive interference, but the intermediate treatment was much 
hindered by the timid character of the patient. 



412 



CHAPTER XXVII. 

DISEASES OF THE TEMPOKO-MAXILLAKY ARTICULATION. 

The tempore -maxillary articulation is, like other joints, the 
subject of inflammation due to constitutional and local 
causes, to which latter its exposed position M'ould seem to 
render it particularly lialjle. Yet it is remarkable that 
acute disease of the temporo-maxillary joint is hardly re- 
corded, and I think the explanation is to be found in the 
fact that it is often confounded with acute affections of the 
ear, and that mischief beginning in the articulation may 
induce purulent discharge from the meatus in children. 

My colleague, Llr. Arthur Barker, in his valuable article 
on Diseases of the Joints {System of Surgery, vol. ii.), men- 
tions that in cases of sup j)u ration of the middle ear, the 
temporo-maxillary articulation may become involved through 
the floor of the meatus, in which a hiatus often exists in 
children. He quotes in proof of this a case which I had 
long under my care, a child, from whose meatus the condyle 
of the jaw was extracted ; but I should rather regard it as a 
case in which, from disease of the temporo-maxillary joint, 
perforation had ensued, and the condyle had found its way 
into the meatus. 

That destructive disease of this articulation is not very 
infrequent, is evident from the number of museum speci- 
mens extant of complete ankylosis, and of the numerous 
cases of fibrous ankylosis which have been met with in 
practice. 

In his " Practical Observations in Surgery" (1816), Mr. 
John Howship describes a case of ** scrofulous inflammation 
of the face followed by ankylosis of the jaw" in a man 
of fifty-six years of age, who dated the origin of the disease 



TEMPORO-MAXILLARY ARTICULATION. 



413 



from a cold taken at the age of four. The original illus- 
tration shows complete bony ankylosis of the lower jaw to 
the temporal bone on the left side. On the right side the 
shape of the joint is considerably modified, as may be seen 
in the specimen in the College of Surgeons' Museum (1949). 

In Guy's Hospital Museum is the skull of a negro who 
had disease of the cervical vertebrte, and complete osseous 
ankylosis of the temporo-maxillary articulation, coming 
on after a wound in the neck from a fork. The history of 
the man, with a drawing of the skull, will be found in 
Mr. Hilton's " Lectures on Best and Pain," 

In the Museum of University College is another speci- 
men (81<9) showing an earlier stage of the same condition. 
The condyle is immovably united to the corresponding part 

Fig. 189. 




of the temporal bone, the contiguous surfaces being very 
irregular but mutually adapted, and separated in part by a 
thin line of shrunken fibrous tissue. Considerable portions 
of each of the surfaces have been destroyed, the condyloid 
part of the jaw is much enlarged in the antero-posterior 
direction, so as to lie in contact both with the glenoid fossa 
and the articular eminence in front of it. Also, in St. 
Bartholomew's Hospital Museum is a specimen (I. 064), of 
which I have been allowed to take a drawing (fig. 189), 



414 DISEASES OF THE 

showing tlie results of disease of tlie right articulation for 
the lower jaw, a quantity of rough new bone having been 
formed, from which the condyle appears to have forcibly 
broken away. 

Cases of fibrous ankylosis of the temporo-maxillary articu- 
lation, recognized and treated as such during life, have been 
recorded by several surgeons, but I would especially refer 
to two published by Mr. Spanton, of Hanley {Lancet, April 
16, 1881), because that gentleman proved the correctness of 
his diagnosis by dividing the fibrous bands with a tenotome 
passed into the articulation, and then succeeded in screwing 
open the mouth. The patients were girls, aged ten and 
nine respectively, and in both cases the disease of the tem- 
poro-maxillary joint had followed scarlet fever. 

I have had the opportunity of watching a case wliich I 
fear will terminate in ankylosis of the jaw, in a gentleman 
aged twenty-five, who was sent to me by my friend, Mr. 
Bate. I saw him first in February, 18G6, when he told me 
that he had the measles badly when nine years old, and 
this was followed by discharge from the left ear, which 
became deaf. The discharge had ceased for two years, when 
in September, 1864, he caught a severe cold, and it recom- 
menced, and at the same time the left temporo-maxillary 
articulation became swollen and stiff, so that he was obliged 
to live by suction for some time. The discharge from the 
ear was very profuse, as much as half a pint at a time, and 
matter burrowed under the tissues of the face as high as the 
orbit, where a small opening formed, and down the neck, 
discharging into the throat for three days. Finding the 
left lower wisdom tooth cut awry and very far back, I 
thought that this might possibly be connected with the 
disease, and therefore had it extracted, with some difificulty, 
by Mr. Mummery. In the following July I found that he 
had derived no benefit from the extraction, and the jaws 
were as firmly closed as before. The space between the 
incisors was \ inch, and rather more between the bicuspids 
on the left side. The mouth did not open so widely as it 
had done eighteen months before, but he had perceived no 



TEMPORO-MAXILLARY ARTICULATION. 415 

difference during the preceding six months. There was no 
external deformity, but he said he heard a grating sound on 
moving the jaw, which was not audible externally. 

This would appear to have been a case of inflammation and 
destruction of the temporo-maxillary articulation, which was 
undergoing cure by ankylosis, as would happen with other 
joints under similar circumstances. It cannot be classed 
with the cases of chronic rheumatic arthritis of the joint, 
since the patient had none of the symptoms of that disorder. 

The only disease of the temporo-maxillary joint hitherto 
generally recognized by surgical authors, has been the so- 
called " sub-luxation" of Sir Astley Cooper. It is an affec- 
tion occurring principally in delicate women, and has been 
thought to depend upon relaxation of the ligaments of the 
joint permitting a too free movement of the bone, and pos- 
sibly (though this is conjecture) a slipping of the inter- 
articular cartilage. From a considerable acquaintance with 
this affection, I believe that it is in many cases, at least, 
unconnected with any slipping of the cartilage, but is due 
to rheumatic or gouty changes in the articulation. The fact 
that these patients suffer most in damp weather and when 
the general health is feeble, sliows that it depends upon an 
arthritic diathesis, and the relief that is obtained from 
counter- irritation and the exhibition of anti-rheumatic or 
anti-gouty remedies, proves that the complaint cannot be due 
to purely mechanical causes. 

The researches of the late Dr. Eobert Adams and Dr. 
E. W. Smith, of Dublin, have shown that rheumatoid arthritis 
occasionally affects the temporo-maxillary articidation, and 
the former author has, in his " Atlas," figured the remark- 
able hypertrophy of the neck of the condyle of the jaw, 
occurring in the case of a woman, aged thirty, to which I 
shall have occasion to refer more particularly later on. 

Cruveilhier, who first described an example of rheumatoid 
arthritis of the temporo-maxillary articulation (" Anatomic 
Pathologique," liv. ix.), says : — "I have never seen the disease 
I call wearing away of the articular cartilages better marked 
than it was in this case. The condyle of the lower jaw did 



416 



DISEASES OF THE 



not exist ; it might be supposed to have been sawn off 
horizontally at the line of junction of the head with the 
neck, and that which remained of the neck had been flat- 
tened. The articular part of the glenoid cavity was repre- 

FiG. 191. 






sented merely by a plane surface ; no trace of inter-articular 
cartilage or cartilage of incrustation existed. Both surfaces 
of the altered articulation were remarkably red." 

I have never had the opportunity of examining a recent 
example of this disease, but as far as can be judged from 
museum specimens, the articular surface of the condyles is 
flattened and somewhat altered in direction in the less 
marked instances (fig. 390), and absor])tion of the neck, 

Fig. 192. 



^^ 





with complete wearing away of the articular surfaces (fig. 
191), occurs in the older and more advanced cases. I agree 
with Dr. Adams, that eburnation of the articular surfaces, 
or the occurrence of porcellanous deposit in the temporo- 



TEMPORO-MAXILLARY ARTICULATION. 



417 



maxillary articulation, is very rare. The description quoted 
front the St. Bartholomew's Catalogue by Dr. Adams refers 
to preparation No. 551 in that museum (fig. 192), and is as 
follows : — 

" There has been disease in one of the articulations of the 
jaw, producing absorption of the articular cartilage, with a 
deposit of bone around the circumference of the glenoid 
cavity. The corresponding condyle is in part removed by 
absorption ; its surface is rough, except at one point, where 
it is highly polished and has an ivory-like texture." 

Enlargement of the glenoid cavity is common in these 
cases, and is well seen in fig. 193, taken from the same speci- 
men in St. Bartholomew's Hospital. Absorption of bone 

Fig. 193. 




must of course occur in these cases, but it is worthy of 
remark that, as pointed out by Dr. Adams, the bone forming 
the fundus of the cavity is not thinned, but, if anything, 
is thicker than in the normal state. The entire disappear- 
ance of the inter-articular fibro-cartilage is, apparently, an 
early event in chronic disease of the temporo-maxillary 
articulation. It had entirely disappeared in all the few 
recorded post-mortem examinations, and was absent in a 
case of hypertrophy of the condyle in the living subject 
which I successfully operated upon. 

E E 



418 



DISEASES OF THE 



Rypertropliy of the Neck and Condyle was observed by Dr. 
Adams in tlie case of rheumatoid arthritis of the tempero- 
maxillary joint already referred to, and is beautifully shown 
in Plate 1 of his admirable " Atlas." Though occurring in a 
woman of only thirty, there can, I think, be no doubt, from 
the description and draM'ings of her hand and feet, that tlie 
patient was the subject of rheumatoid arthritis. It is by no 
means certain, however, that the hypertrophy of the neck 
and condyle must be considered to be the results of that 
disease, for, as I shall show, this same rare deformity has 
been found in patients otherwise healthy. 

Fig. 194 shows a lower jaw so like that figured in Adams' 
" Atlas" in every respect, that the preparations are evidently 

Fk;. 104. 




identical in their nature. It was presented to the College 
of Surgeons' Museum (2205) by ]\Ir. Jeremiah McCarthy, 
and is thus described by Mr. Eve : — 

" A lower jaw with a mass of bone, having somewhat the 
form of an inverted pyramid, attached to the thickened neck 



TEMPORO-MAXILLARY ARTICULATION, 



419 



of the right condyloid process. The upper surface of the 
mass, corresponding to the base of the pyramid, is flat and 
smooth as if it had been covered with fibro- cartilage (fig. 
195). Upon its inner side is a deep indentation, from which 
a fissure extends outwards and downwards nearly to the 
external surface of the bone. The indentation and the fissure 
constitute the upper boundary of a portion of bone which, 

Fig. 195. 




from its form and position, might be taken for an enlarged 
condyle. The right half of the jaw is larger in all its dimen- 
sions than the left half, the breadth of the horizontal ramus 
in front of the angle being double that on tlie left side, 
which, from the slenderness of the coronoid and condyloid 
processes, appears atrophied. From a middle-aged man, who 
died with apoplexy. There was a remarkable deformity of 
the face from the deviation of the symphysis from the middle 
line ; and the projection of the enlarged condyle was con- 
siderable. The base of the skull was not examined, and 
nothing was found in the post-mortem examination except 
atheroma of the vessels. Nothing unusual had been noticed 
about his mouth in childhood, nor could any account of an 

E E 2 



420 DISEASES OF THE 

injury be obtained." (See Patliological Society's Transactions, 
vol. xxxiv., 1883.) 

In the same volume of the Pcdhological Society s Transac- 
tions will be found the record of a remarkable specimen of 
hypertrophy of the neck and condyle of the jaw, removed 
by myself from a woman, aged thirty-six, whose face had 
for ten years become gradually more deformed, by the in- 
creasing displacement of the chin to the right side and the 
projection outwards of the left condyloid process. The 
movements of tlie jaw were restricted, and the length of the 
left ascending ramus was three inches, of the right one inch 
and a half. She had an attack of hemiplegia^ implicating 
the left side of the face, when she was twenty-five years 
of age, and from this affection her limbs had recovered 
perfectly and her face partially. 

Fig. 196. 




The appearance of the patient (who was sent to me by Dr. 
Williams, of Sherborne) is seen in fig. 196, and the piece of 
bone removed is accurately drawn in the lithographic plate 
{v. frontispiece), the hypertrophied condyle measuring one 



TEMPORO -MAXILLARY ARTICULATION. 421 

inch and three-quarters from before backwards, and one inch 
across, and being covered with fibro-cartilage. A section of 
the preparation shows it to be composed of cancellous bone 
with large rounded spaces, and its walls are formed of a thin 
layer of compact bone. The fissure observed in Mr. ^McCarthy's 
does not exist in this specimen, If the condyle thus shown is 
compared with fig. 195, which represents the condyle of Mr. 
McCarthy's case, of the natural size, there can be little doubt 
that xny preparation, Mr. McCarthy's, and Dr. Adams's all 
belong to the same category ; and yet in Mr. McCarthy^s 
probably, and certainly in my own case, this was the only joint 
affected. It must be concluded then, I think, that hypertrophy 
of the neck and condyle may occur in otlierwise healthy 
patients, and I believe that I saw, in consultation with Mr. 
Nathaniel Stevenson, the early stage of this curious con- 
dition in a young healtliy lady of about twenty, in whom 
the lower teeth had gradually become displaced from no 
known cause, so as to disarrange the normal bite. I here 
detected, what was then new to me, some hypertrophy of the 
neck of the jaw on one side, and recommended blistering and 
a course of iodide of potassium without any marked benefit, 
except that the deformity has not increased. In the patient, 
whose portrait is given in fig. 196, the deformity was so great 
as to warrant surgical interference, and the result has been 
very satisfactory, the face being brought straight and the 
patient having free movement of the jaw. 

The Treatment of inflammation of the temporo-maxillary 
joint has hitherto been, in chronic cases, the application of 
blisters and the use of a bandage — particularly an elastic 
bandage at night. Dr. Goodwillie, of New York, has, how- 
ever, contrived an ingenious method of fixing the lower jaw 
effectually in cases of arthritis, which will be best described in 
his own words {Archives of Medwine, New York, June, 1881) : — 

" The method that I employ is as follows : In this case 
the patient is under the anaesthetic effect of morphine and 
nitrous oxide. If there is any rigidity of the muscles^ cau- 
tiously force open the mouth and take an impression of 
either the upper or lower teeth, and a rubber splint is made 



422 



DISEASES OF THE 



from the cast to cover over all the teeth in one jaw. Upon 
the posterior part of this splint is made a prominence or 
fulcrum (D), so that when the mouth is closed the most 
posterior teeth close upon it, while all the anterior teeth are 
left free. The next step is to take a plaster of Paris im- 
pression of the chin, and from this make a splint [A). On 
each end of the splint is made a place for fastening elastic 
straps [B) that pass up on each side of the head to a close- 
fitting skull-cap (C). See fig. 197. 

'• When the apparatus is in place and the elastic straps 
tightened so as to lift the cliin, then pressure is brought to 
bear on the fulcrum at the posterior molar tooth, and so by 
this means extension is made at the joints, and the inflamed 
surfaces within the joints are relieved from pressure ; then 
immediate relief is experienced." 

Fig. 197. 




"m 



^^^:'^^^^^mmm'^ 



I have no experience of this method, but it appears to be 
based upon sound surgical principles, and the cases illustra- 
tive of its use given by Dr. Goodwillie attest its usefulness. 

In the cases of fibrous ankylosis resulting from the cure of 
arthritis, it is open to the surgeon to have recourse to me- 
chanical means to break down the adliesions, and to illus- 



TEMPORO-MAXILLARY ARTICULATION. 423 

trate the difficulties to be overcome, I may refer to another 
case of Dr. Goodwillie's {Nno York Medical Journal, July, 
1875) : — The patient was a girl of ten, who, five years be- 
fore, had fallen over the bannisters, breaking and dislocating 
the jaw, with the result of the jaws being firmly closed. 
The apparatus employed is seen in fig. 198. 

Fig. 198. 




One of the chief sources of interruption in treatment is 
periodontitis from the great amount of force used on the 
teeth. To prevent this, Dr. Goodwillie protects them with 
an interdental splint of hard rubber. These splints at first 
are necessarily very small, and confined to the front teeth ; 
but, as the case progresses, longer and more perfect ones are 
made. In this case the rubber splints were enclosed in 
metal splints made of German silver, as this metal is tough 
and unyielding. These splints were made fast to the teeth 
by straps that passed from strong wire arms at the sides to a 
skull-cap, and the lower one was strapped to a pad on the 
chin. This pad was also attached to the lower splint by 
means of a ratchet and spring. 

From the point of each splint an arm, three- fourths of 
an inch broad, extends out one and a quarter inch, and to 
these is clasped the oral speculum when in use (fig. 198). 
The inclined planes of the speculum pass in between these 
arms, and they are held by clasps. The inclined planes 
are attached by movable joints to a distending forceps, so 
that when the handles are approximated, the inclined planes 
are separated at their attached ends. Each handle is made 



424 DISEASES or THE 

ill two sections, and the spring that separates the handle is 
enclosed between them to protect them from injur}'. 

In forcing the speculum between the splints, the instru- 
ment is grasped by one of the handles, and when in place 
both handles are approximated. If more force is desired, 
or the mouth is to be held open at any point, the screw at 
the handle may be used. 

In stretching the masseter and temporal muscles. Dr. 

Fig. 199. * Fig. 200. 



Goodwillie uses ao oral speculum, devised by him some 
years ago (fig. 199). It consists of a shaft, to the flat end 
of which are attached two wings or inclined planes, upon 
which the teeth rest. The other end of the shaft has a 
thread cut on it, and a screw ; this passes through a handle, 
one end of which is wedge-shaped. By turning the screw 
on the other end of the handle, the inclined planes diverge 
or converge. Fig. 200 represents a spiral-spring speculum 
for the patients to employ by placing it between the teeth 
and biting upon it. Longer springs are used as the mouth 
gradually opens. 

It need hardly be said that treatment by this method 
would extend over many months, and would severely try the 
endurance of both patient and surgeon. 

A simpler method is the division of adhesions formed 
between the condyle and glenoid cavity, as practised by Mr. 
Spanton in the cases already referred to, in both of which, 
as I learn from that gentleman, a good result ensued. I 
have no experience of the proceeding, and it has its diffi- 
cidties, but these may doubtless be overcome. 

Lastly, there is in cases of fibrous ankylosis the possibility 



TEMPORO-^IAXILLARY ARTICULATION. 425 

of removing tlie condyle, as has been done by Mr. Davies- 
Colley, and probably by others ; or, as proposed by Dr. 
Ewing Mears (American Journal of Medical Science, Oct. 
1883), to divide the ramus of the jaw and excise the condyle 
with the coronoid process and sigmoid notch. 

A case of removal of hoth condyles for fibrous ankylosis is 
quoted by the Wiener Med. Woclienschrift, of July 6, 1872, 
from the proceedings of the Eoyal Academy of Medicine in 
Bologna. It occurred in the practice of Dr. Bottini. The 
patient was a lad, aged seventeen, who, at the age of seven, 
had fallen on the jaw, and had gradually lost the power of 
opening his mouth, so that at last for some months he was 
unable to separate the jaws to any extent. Dr. Bottini 
introduced wedges, but these were vary irksome to the 
patient, and were removed. Eesection of the articular head 
of the bone was then performed on one side ; this had no 
noticeable result, but on the operation being repeated on the 
other side, the jaw could be moved freely. At the end of 
six weeks the wound had healed, and the motion of the jaw 
was normal. The only morbid change that could be dis- 
covered was absence of the inter-articular fibro-cartilage. 

In cases of rheumatoid arthritis in which the suffering is 
great, and in cases of osseous ankylosis of the temporo- 
maxillary articulation, excision of the condyle seems to offer 
the best means of giving relief. The first removal of the 
condyle was by Professor Humphry, of Cambridge {Associa- 
tion Med. Journal, 1856), and was undertaken for chronic 
rheumatic arthritis. He exposed the condyle by a curved 
incision from the side of the orbit across the zygoma to the 
ear, passing a little above the temporo- maxillary articula- 
tion, and a second incision from the termination of the first 
directly upwards in front of the ear across the zygoma again, 
avoidhig the temporal artery. The flap thus made was 
reflected, and the neck of the condyle cut tlirough with a 
narrow saw. 

In cases of complete synostosis, resection of tlie condyle 
appears to offer the best and safest method of treatment. In 
1874 Dr. Gross, of Philadelphia, resected the condyle with a 



426 DISEASES OF THE 

portion of the neck of the jaw in a girl of seven, but does 
not mention the method lie pursued. Mr. Croft has shown 
me the photographs of a child in whom he resected the 
condyle on both sides consecutively, with very good results, 
and no doubt the operation has been performed by other 
surgeons. In 1883 I exposed the ankylosed joint in a boy of 
seven by an incision in front of the ear, and with a chisel 
divided the neck of the bone, and removed half an inch of 
bone in the situation of the condyle, with very good results 
as regards movement, and with no obvious damage to the 
facial nerve. 

A case of complete synostosis of the jaw was successfully 
treated by a different method by Dr. James Little, of New 
York, in 1873 {Trans. New York State Med. Soc, 1874). 
The patient M^as nineteen years of age, and had some years 
before suffered from suppuration of the temporo-maxillary 
articulation, leading to ankylosis. Dr. Little made an in- 
cision along the lower border of the jaw, and turned up the 
masseter, wdien the neck of the condyle was seen to be very 
much enlarged, and continuous with the temporal bone. 

A trephine half an inch in diameter was then applied, 
and a button of bone f of an inch in thickness was removed. 
The portion of bone on each side of the opening was then 
cut through wdth a chisel, and the neck of the condyle cut 
away piece by piece, so as to leave no portion projecting 
fi'om the temporal bone. The result was quite satisfactory. 

A similar operation, but performed by a different method, 
was successfully undertaken by Dr. Eobert Abbe, of New 
York {Nci'j York Medical Journal, A^iril, 1880), in a boy of 
ten, who had suffered from otitis media and suppuration of 
tlie joint some years before, A vertical incision was made 
in front of the ear, and a horizontal one meeting its upper 
end was carried along the lower border of the zygoma. The 
parotid with the facial nerve was drawn down, and with a 
periosteal elevator the posterior fibres of the masseter were 
cleared away, and the articulation exposed. A narrow 
osteotomy chisel was now applied to the neck of the condyle, 
and carefully driven half through the bone, and by forcibly 



TEMPORO-M AXILLARY ARTICULATION. 427 

opening the mouth the bone was broken tlirough. The neck 
of the condyle was then carefully removed piecemeal, but the 
condyle was left in situ. The result was satisfactory. 

Sedillot mentions (*' Medecine Operat.," ii. p. 30) that in 
a case of true ankylosis of the temporo-maxillary articula- 
tion, M. Grube, in 1863, carried a straight chisel through 
the mouth to the neck of the jaw, which broke by hammer- 
ing. Some months later he divided the masseter subcuta- 
neously, and the cure, by the formation of a false joint, was 
permanent. In 1879, I performed the same operation in a 
child of six, but the results were unsatisfactory. Suppura- 
tion was set up, and required an external opening, and the 
movement, which was free at first, became as limited as 
before the operation. It would appear, therefore, that mere 
division of the neck of the Ijone does not offer such good 
prospect of a pernument false joint as removal of the neck 
or the condyle, though these operations are necessarily more 
severe. 

Esmarch's operation performed in front of the masseter is 
of course as applicable to cases of ankylosis from disease of 
the joint as to cases of cicatrix, and Fischer {British Med. 
Journ,, June 1, 1872) appears to have performed the opera- 
tion on both sides of the jaw in a case of bilateral ankylosis 
of the temporo-maxillary articulation with very good result, 
the patient obtaining complete and useful control over the 
central movable portion of the jaw. 



428 



CHAPTEK XXVIII. 



DEFORMITIES OF THE JAWS, 



The scope of this work does not eml3race those congenital 
deformities of the gum and pahite which are familiar to the 
surgeon in combination with hare-lip, but there are certain 
examples of deformity, the result of disease, which may be 
conveniently grouped together here. 

In describing the tumours of the jaw, mention has been 
made and drawings given of cases of deformity the result of 
pressure upon the opposite jaw of some growth of large size ; 
thus, at page 332 will be found an instance of deformity of 
the upper jaw, due to the pressure of a large fibrous tumour 
of the lower jaw ; and at page 278 an example of deformity 
of the lower jaw, due to the pressure of a large osseous 
tumour of the superior maxilla. Tumours witliin the mouth, 
unconnected with the jaws, may, however, induce deformity 
mechanically, hypertrophy of the tongue being the disease 
most frequently met with, of whicli several instances will be 
found in vol. xxxvi. of the Medico- Chirurgical Transactions, 
in papers upon that disease, by Dr. Humphry, of Cambridge, 
and Mr. Joseph Hodgson. Dr. Humj)hry's patient was a 
girl of eleven years, who had had a much hypertrophied and 
prolapsed tongue for eight years. " Owing to the constant 
pressure of the tongue on the mental portion of the lower 
jaw a curvature had taken place in that bone, just in front 
of the masseter muscles, in such a manner that a wide 
interval always existed between the incisors and bicuspids of 
the two jaws. Even when the mouth was closed — that is to 
say, when the corresponding molar teeth were in contact — 



DEFORMITIES OF THE JAWS, 429 

this interval between the incisors measured nearly two 
inches, being increased by the horizontal direction which 
the inferior incisoi'S and the alveolar process of the lower 
jaw had assumed. These were so placed as to form a wide 
channel in which the tongue rested. Moreover, the teeth, 
especially the two central incisors, were further apart than 
natural, and encrusted with tartar, which in some measure 
filled up the spaces between them, and prevented their 
sharp edges from injuriously pressing upon the tongue." 
The deformity, therefore, closely resembled that seen in 
fig. 201, which was due, however, to external causes. Dr. 
Humphry removed the anterior part of the tongue success- 
fully, and then endeavoured to remedy the deformity of the 
jaw by fitting a cap of calico and metal to the head, with 
a hooked bar of iron projecting from it like a horn over the 
forehead. The bar was attached to the hinder part of the 
framework of the cap by a hinge and to the forepart by a 
screw, which enabled the surgeon to alter its elevation 
according to circumstances. A thick belt of india-rubber 
passed from the hook beneath the chin, and exerted con- 
siderable pressure upon it. The apparatus was worn for 
several hours at a time. When its use was commenced, on 
January 18, four months after the operation on the tongue, 
tlie interval between the maxillary alveoli was If inch, 
having decreased about a quarter of an inch. On February 
22 it was II inch, and in August ^ of an inch. After this 
the change took place very slowly, though the deformity 
was at length almost removed. 

A very similar condition of the lower jaw, but in an 
earlier stage, existed in a child aged three, from whom Sir 
J. Paget successfully removed the hypertro23hied portion of 
the tongue, in February, 1864. (Lancet, April 16, 1864.) 

Mr. Oliver Chalk has also narrated, in the Pathological 
Tra7isactions, vol. viii., a case of deformity of the jaw de- 
pendent upon enlargement of the tongue in which he con- 
sidered that a partial dislocation of the jaw was produced, 
and where benefit was derived from the use of an elastic 
support. 



430 



DEFORMITIES OF THE JAWS. 



The influence of the habit of sucking the thumb upon 
the position of the front teeth is generally acknowledged, 
and the practice if persisted in, may produce very con- 
siderable deformity of the jaws. Some drawings illustrating 
a paper on this subject, by Mr. Yasey, in the Patholofjical 
Transactions, vol. vi., show the resulting deformity ex- 
tremely well. Dr. Thomas Ballard has also called attention 
to the deformity resulting from the habit of "tongue- 
sucking," to which he attributes many of the ailments 
of children. 

The influence of cicatrices outside the mouth in pro- 
ducing deformity of the jaw by their contraction in early 
life is well ascertained, and every surgeon must have met 
with painful examples of the kind. Fig. 201, from Mr. 

Fig. 201. 




Tomes' work, shows the condition of the lower jaw in a 
young woman twenty-two years of age, her chin having 
been drawn down towards the sternum by a broad cicatrix, 
consequent upon a burn received when five years old. 

In all these cases the deformity partakes of the same 
character, and if seen early enough is to some extent 
amenable to treatment. The slighter cases depending upon 
thumb-sucking are usually treated by the dental surgeon, 
who in rectifying the position of the teeth necessarily im- 
proves the condition of the jaw. In the more severe cases, 
constant support by an elastic band making traction upon 
the jaw will be of much service, as in the cases of Dr, 



DEFORMITIES OF THE JAWS. 431 

Humphry and Mr. Chalk. The cases depending upon the 
contraction of cicatrices can only be relieved by treating 
the cicatrices, and the pressure of a screw-collar, worn for 
the purpose of extending these, will do much to restore the 
shape of the jaw, if the case is not one of too long standing. 
Disease originating within the mouth may lead to ulti- 
mate deformity of the jaws ; thus caiicrum oris, in addition 
to leading to closure of the jaws, as described in a pre- 
vious chapter, may lead to very considerable deformity of 
the alveoli. A case of closure with deformity thus caused, 

Fif). 202. 




successfully treated by Mr. Bernard, of Clifton, has been 
already referred to (p. 403) ; but a still more remarkable 
case was under the care of my friend, the late Mr. W. 
Harrison, to whom I am indebted for the accompanying 
engravings of it. The patient, aged thirty-six, had suffered 
in childhood from ccmcrum oris, which had destroyed the 
greater part of the right cheek. His appearance is shown 
in fig. 202, and it will be seen that the lips were widely 
separated, and that a considerable protrusion of the alveolar 
processes of both jaws, with their teeth, had taken place 



432 



DEFORMITIES OF THE JAWS. 



between them. Behind this point the jaws were united 
by a bridge of bone, and the patient, who was totally unable 
to open his mouth, fed himself through an aperture between 
the teeth on the left side. In October, 1867, Mr. Harrison 
extracted the seven teetli which projected, and reflected the 
gums from the adjacent alveoli, when as much of them as 
was thought desirable was removed with the bone-forceps. 

Fig. 20.3. 




The molar teeth, which had been driven into the interior 
of the mouth, were then extracted with some difficulty, 
when a pillar of bone, about the size of an ordinary lead- 
pencil, connecting the alveoli, was brought into view, but 
was not interfered with. Tlie gums were brought together 
with stitches, and the operation was concluded. The ap- 
pearance of the patient some weeks afterwards is shown in 
fig. 203. 

The patient having been transferred to the care of Mr. 
James Lane, that gentleman proceeded to perform a plastic 
operation for the improvement of the condition of the lips. 
A very long \/-shaped incision was made, extending from 
the extremities of the lips (which were firmly attached to 
the alveoli) to a point about an inch in front of the ear, 



DEFORMITIES OF THE JAWS. 



433 



thus embracing within it the cicatrix of the original disease. 
The tissues were freely dissected from the upper and lower 
jaws, and were brought together over the old cicatrix. An 
incision, two inches long, was made along the lower border 
of the jaw, to enable this to be done without too great ten- 
sion, and the parts were held together with hare-lip pins and 

Fig. 204. 




sutures. The operation was perfectly successful, and the 
subsequent appearance of the patient is shown in fig. 204. 

The interesting details of this case will be found in a 
paper read by Mr. Harrison, before the Odontological 
Society, in May, 1868 {British Juurnal of Dental Science, 
May, 1868). 



F F 



434 



APPENDIX OF CASES. 



Case I. — Compound Comminuted Fractures of both Upper cmd 
Lower Maxillm, with Extensive Laceration of Face, &c. — 
Recovery. Under the care of Mr, E. Stamer O'GrRADY, 
r.R.C.S.I., M.B., &c., Mercer's Hospital, Dublin. 

A strong healthy man was admitted a few minutes after 
recei\ing severe injuries by the wheel of his vehicle, in 
which was some hea^^y macliinery, passing over his face. 
Both upper jaws were smashed away from all their osseous 
attachments, and completely detached from one another ; 
the left one being severely comminuted, and the molar 
teeth pinched together in pyramidal form. The left side 
of the soft palate, and for some distance down along the 
side of the tongue, were extensively torn. The parts here 
gaping widely, and forming a large chasm, the sides of 
which were tags of muscular tissue and tendinous fibre. 
The lower jaw was also broken- in different places, one 
fracture running obliquely down to the left of the incisors, 
another brandling ott' from it, and breaking away the portion 
of bone bearing these teeth. There was also comminuted 
fracture of the mental prominence. The left ear was nearly 
off, and considerable damage was done to the face generally, 
more especially to the region of the nose, which was fractured, 
and the forehead distended with air, which, with the efiused 
blood, speedily weighed down the upper eyelids, and totally 
blinded the patient. The upper lip beneath the nares was 
entirely cut tlirough. Haemorrhage from the mouth was free 
and persistent ; the flow coming from Ijehind the displaced 
teeth. No ligaturable spot could be found. Careful and long 
sustained digital pressure by Mr. Finlay, one of the resident 
pupils, failed to check it, the comminuted and loosened state 
of the jaw affording no stay against which to exercise 
effective pressure. With considerable cUfticulty the molar 
teeth were wired into line, and then a long strip of lint. 



COMPOUND COMMINTTTED FRACTURES, ETC. 435 

wliicli had previously been steeped in an aqueous solution 
of percliloride of iron and dried, was carefully packed up 
behind them. This stopped the further loss of blood, which 
in the aggregate had been great. The lower jaw was wired 
into position, suitably bandaged, and the superficial wounds 
attended to. Five hours after the accident, and as it so 
happened, at a moment when Mr. O'Grady was in the ward, 
he suddenly threw his arms up, and after a few paroxysmal 
efforts, ceased to breathe. Bronchotomy was immediately 
practised ; the tube being opened above the isthmus of the 
th}Toid, and resuscitation soon efiected. Shortly thereafter 
over a pint of clotted blood was vomited. At midnight 
respiration was quite free, and the eyelids could be partially 
opened. The tracheotomy tube, after having been experi- 
mentally corked for some hours, was removed at the begin- 
ning of the third day. Next day there was some difficulty 
of breathing ; there was now considerable redness, swelHng, 
bogginess, and tenderness at the root of the neck. This 
local inflammatory attack proved to be one of severe type, 
attended with profuse cellulitis, and required numerous 
incisions on the neck and front of the thorax to evacuate 
the pus and sloughs. Its course was attended with delirium 
and much prostration. Twelve days after the accident one 
of the dislocated incisor teeth fell out. The condition of the 
neck was now improving, and from the cuts the discharge 
was healthy pus. Still the man was slow to recover strength, 
it being three weeks before he could sit up. Occasional flying 
abscesses continued to form, and from one of these, forty-two 
days after the accident, a necrosed piece of the lower jaw 
was picked out. The wires from the upper jaw were 
removed at this time ; union being good, and the teeth firm. 
No union had occurred in the lower jaw, which, too, had 
sedulously been kept wired and maintained in good position. 
Patient, now fairly well and strong, was allowed to go to his 
home in the suburbs. He attended regularly as an extern, 
and sixty-one days after the accident the wiring was removed 
from the lower jaw, union being then firm. A good deal of 
contraction and bad shape of the fauces existed where the 
parts had been torn. As time advanced this toned down, 
and in another month, during which two further abscesses 
required opening, the man, now in perfect health, was dismissed 
from treatment. — Medical Press and Circular. 



F F 2 



436 APPENDIX OF CASES. 

Case II. — Mr. Holmes' Case of Fracture of the Neck of the Con- 
dyle of the Lower Jaw, with Displacement of the Loioer Frag- 
ment into the Meatus Auditor ius Externus. — Serous Discharge 
from the Ear. 

J. L., aged fifty, was admitted into St. George's Hospital on 
July EO, 1860. It seemed that he had been sleeping in a 
hay-loft, and being drunk, had walked out of the window 
during the night. He was found lying on the ground, and 
was brought to the hospital at half-past four a.m. He was 
then sensible, but seemed to be stupid from drink. There 
were several cuts about the face, and one beneath the chin. 
Blood was flowing from the right ear. There was some 
ecchymosis about tlie right temporo-maxillary articulation, and 
crepitation was detected in that neighbourhood, though not very 
distinctly. He was unable to move his jaw, and complained 
of intense pain in trying to do so. The mouth was drawn to 
the right side. The pupils were natural. On the following 
day considerable serous discharge was noticed to flow from 
the ear. In the evening he was very restless and feverish ; 
but no head-symptoms were observed. Next day (the 
third) the discharge continued, mixed with blood, and there 
was great pain in the head. He had considerable difficulty 
in speaking. On the fourth day from the accident the 
symptoms of delirium tremens became more marked, and he 
sank rapidly, dying in the evening. Other extensive injuries 
existed of which no mention need be made here. It is 
sufficient to say that the skull, the brain, and the cerebral 
membranes were perfectly healthy. 

On examining the tympanum, traces of blood were found in 
the mastoid cells, but hardly a drop in the tympanum itself. 
A probe passed into the tympanum through the external 
meatus without resistance, and after dissection a large rent 
was seen at the upper part of the membrana tympani. This 
was probably, in great part, produced by the dissection. The 
meatus externus was full of clotted blood, and serous fluid 
could be seen exuding from the ear. The temporal bone was 
carefully examined, but no fracture was found. The lower 
jaw was fractured in two places — viz., through the base of the 
coronoid process, separating that process fi'om the rest of the 
bone, and through the neck of the condyle. The condyle 
remained in position, and the joint seemed in all respects 
healthy. The lower fragment was somewhat displaced, and 
had produced laceration of the meatus, separating the 



UNUNITED FRACTURE OF LOWER JAW. 437 

cartilaginous from the osseous portion for nearly half of its 
circumference. A large quantity of blood lay around the 
fracture, and in the neighbourhood of the bone there was 
some fluid of a sero-purulent appearance. The preparation 
submitted to the Society consisted of three fragments of the 
lower jaw, and the greater part of the temporal bone, showing 
the laceration of the meatus auditorius. In consequence of 
the dissection that had been undertaken in order to open the 
tympanum and mastoid cells, the integrity of the petrous por- 
tion of the temporal had lieen destroyed, but the absence of 
fracture and the course which the blood had taken were still 
shown by the contrast between the meatus, which was lined 
with clotted blood, and the mastoid cells and tympanum, in 
which hardly a trace could be found. — Transactions of the 
Patliological Society, vol. xii. 

Case III. — Ununited Fracture and Necrosis of the Lower Jaw, 
ivith Salivary Fistula, from old G-unshot Injury — Operation 
— Satisfactory Result. Under the care of the Author. 

James P., aged tliirty-two, was admitted, August 19, 1862, 
into the Westminster Hospital, under the care of the author, 
for necrosis of the lower jaw\ 

History. — In March, 1860, when in the 64th Eegiment, and 
whilst marching through Central India, he was struck on the 
right side of the lower jaw by a spent bullet, fired by some 
hill robbers. He was stunned for a few moments, and had 
hsemorrliage for half an hour. He went to the rear, but was 
able to continue the march. The following day he went into 
camp hospital, under the regimental surgeon, at which time 
the parts about the wound were much swollen. The wound 
was bathed with Avarm water, and the swelling was rubbed 
with soap liniment. At this time he was able to open his 
mouth and eat on the left side without pain ; but three weeks 
afterwards, having attempted to eat on the right side, he felt 
a grating sensation and much pain, and told the surgeon his 
jaw was broken ; but the surgeon did not believe him. The 
last molar tooth was found to have been displaced and to be 
lying horizontally, and attempts were made to extract it, but 
unsuccessfully. It gave him extreme pain, and the surgeon 
then admitted that the jaw was splintered. A gutta-percha 
splint was now moulded on, and a bandage applied for eight 
days, the wound having by this time closed. On April 9, 
1860, he was admitted into the Kurrachee Hospital, and 



438 APPENDIX OF CASES. 

another splint was applied, and kept on three or four days, 
when a large abscess formed. It was opened, and a large 
quantity of matter discharged, and the wound then healed. 
Another aliscess began to form immediately l)ehind the 
opening, and just below the original wound ; and this also 
was opened and poulticed, and has never closed. The 
regiment arrived at Dover, on August 6, 1861, and the 
man was doing duty ; but the cold weather coming on, the 
wound inflamed and swelled up again, and he was sent into 
Fort Pitt, on May 1-i, 1862. During the whole of this time 
he felt a numbness over the chin and all round the mental 
foramen. Various attempts had been made to extract the 
last molar tooth, which Dr. Long-more removed with some 
difficulty. After the patient had been in the hospital for 
twenty-one days, he was, on June 26, 1862, invahded and 
discharged from the service. 

Present Condition. — There is an open sinus on the right 
angle of the jaw, leading down to dead bone and into the 
mouth, and he can blow air tln-ough the aperture. He can 
bite perfectly with the left side, and can open his mouth as 
wide as most people. He does not complain of any pain in 
the part, and his general health is good. He has never had 
syphilis. A small piece of bone has worked out into the 
mouth since admission. On lookina; into the mouth, a good 
deal of swelling about the ramus of the jaw is seen. The 
second molar tooth is in situ, but loose. 

OjMration, Aug. 26. — Chloroform having been adminis- 
tered, the author proceeded to enlarge the external opening, 
and removed, with the gouge, several pieces of necrosed bone. 
He found that the jaw had Ijeen fractured, that it had not 
united, and that the upper fragment was tilted forwards by 
the temporal muscle, thus causing the projection in the mouth 
before noticed. The wound was filled with lint, and a com- 
press applied. 

28th. — Face considerably swollen, Init pain slight ; wound 
discharging freely ; can blow air easily through the wound 
from the mouth. 

Sept. 10. — Wound has much decreased in size; two or 
three small particles of bone have worked out through the 
mouth. 

20th. — The last molar tooth of the right side being quite 
loose, was extracted. 

28th. — Says that the opening from the mouth has appeared 
larger since tlie extraction of the tooth, so that he is unable 



FRACTURE OF THE JAWS — WIRE SUTURE. 439 

to hold fluid on that side of his mouth ; external wound very 
much diminished in size. 

Nov. 4. — The wound having degenerated into a small 
fistula, and there being no evidence of further disease of the 
jaw, the author determined to attempt to close it. For this 
purpose, he introduced a narrow knife into the opening, and, 
by rotating it, pared the surface, including the skin, and then 
brought the edges together with a curved needle and twisted 
suture, over which collodion was applied. 

7th. — One end of the needle having cut its way out, it 
was removed altogether. The wound was not united. The 
edges were now brought together with a strap and pad and 
bandage. 

14th. — Wound much diminished in size ; the edges touched 
with nitrate of silver. 

22nd. — No fluid now passes through the fistula, and he says 
that he can feel with his tongue that the internal wound has 
healed. 

26th. — External wound closed. 

Dec. 9. — Discharged cured. The movements of the jaw 
are much freer than they were, and he can eat on the wounded 
side without pain or inconvenience. The false joint does not 
appear to afiect in any way the powers of mastication or 
articulation. — Medical Times, January, 1863. 

Case IV. — Fracture of the Jmvs — Wire Suture. Under 
the care of Mr. Eushton Parkee, 

A boy, aged twelve, was brought to the Stanley Hospital on 
September 4, 1875, having half an hour previously fallen 
a depth of about six feet into a neighbouring sandstone 
quarry, some of the loose stones of which had crushed and 
injured his face. The left cheek was raw from general abra- 
sion, and the lower lip split and ragged all over the red 
margin. The left upper jaw was obviously depressed, its front 
teeth and their alveolar margin driven in, and a perceptible 
difference of level between the hard palate of this and the 
right side. 

The lower jaw was fractured at the first left bicuspid tooth, 
the break passing obliquely downwards and backwards, the 
inner margins of the fragments being exposed, rendering the 
fracture compound. The displacement here was considerable. 
There was, in addition, free bleeding from the right ear. 

In about an hour later the jaw was drilled and wired. He 



440 APPENDIX OF CASES. 

was now much l)laiiclied, and his pulse very feeble and quick ; 
the bleeding continued from the ear, l^ut he was quite con- 
scious and not in j)fiin. Intense ecchymosis of the eyelids 
had now come on, greatly increasing the disfigurement. The 
bicusj^id tooth at the seat of fracture was first withdrawn, as 
a precaution to ensure union. I then held the jaw with the 
left hand, and the handle of an Archimedean drill with the 
right, while the house-surgeon worked the drill. Two drill- 
holes were made, one in front of, and the other behind, the 
fracture, both being directed below the level of the inferior 
dental canal, so as to avoid wounding the nerve. 

The front drilling was performed simply through the jaw 
after turning down the lower lip ; but that of the posterior 
fragment, being behind the corner of the mouth, was per- 
formed by piercing the cheek from the outside, drilling the 
bone there, and passing the wire through bone and clieek ; 
the wire was then picked up from inside the cheek by 
incising the mucous membrane under which it lay, the hole in 
the cheek being then done with and left to heal. 

Each end of the wire was then twisted into a coil by means 
of the key devised by Mr. Hugh Owen Thomas, of Liverpool, 
which is simply a steel rod with a slit at the end, the coil 
in each case lying on the outside of the bone, but inside 
the lip and cheek. In returning the wire from the inside 
through the drill hole, a straight hollow needle was used ; this 
being easily introduced from the outside, and taking the tip 
of the wire which is then withdrawn with the needle. When 
the wire was twisted up the apposition of the fragments was 
perfect, and the only subsequent treatment adopted was 
frequent washing and wiping of the mouth and injured parts. 

No dressing or bandages of any description were used, and 
the depression of the upper jaw was disregarded. The bleed- 
ing from the ear ceased the same evening, and the boy never had 
any particular discomfort, and slept well each night afterwards. 

On the following day the key was introduced into one of 
the coils of wire to tighten it up, and about a quarter of a turn 
given ; after which the wire was not again interfered with 
until withdrawn. 

He was kept in bed aljout a week, and fed on liquid diet 
for about a fortnight, by which time distinct union had taken 
place, as exhibited by an almost complete absence of tender- 
ness on straining the fragments. 

He lost three upper incisor teeth and the left canine, and 
their alveoli necrosed, during his convalescence. The left 



SHELL WOUND OF JAW. 441 

lower second milk molar was shed during this period, and the 
permanent bicuspid appeared in its place. 

The wire was cut and withdrawn twenty-six days after 
being put in, consolidation being firm, and some periosteal 
callus ha%ing formed. 

An abscess formed in the cheek at the seat of fracture, and 
left a sinus leading to bone ; this, however, was healed com- 
pletely in ten weeks. 

His appearance more than three months after the accident 
is somewhat peculiar, as the injury to the upper jaw has im- 
parted a curious vacant expression to his face, the lips, too, 
being a little apart. This is mainly due to the absence of his 
front teeth and their alveoli, the place of which has granulated 
up and cicatrised ; the deformity due to the depressed maxilla 
alone being now but slight ; when complete contraction of the 
cicatrix has taken place he will be able to have a plate 
and some artificial teeth, wdiich will probably restore his 
natural expression. The lower jaw is in every respect satis- 
factory, strong, and without any deformity. 

Case V. — Extensive Injury to the Jaws hy Shell — Secondary 
Hcemorrhage — Ligature of Common Carotid Artery — Death 
from Cholera. By Dr. D. Lloyd Morgan, E.K (Notes 
by Dr. Birch, E.N.) 

William Howden, aged twenty-six, a marine of H.M.S. 
Euryal'us, was in the Japanese war, and was struck on the 
loth of August, 1862, by a portion of a ten-inch shell. The 
right side of the neck and face was frightfully shattered, 
the wound extending from the corner of the mouth as far 
back as the zygoma superiorly, and the sterno-mastoid a little 
below the angle of the jaw inferiorly, the mouth being laid 
open. The body of the jaw on the right side, from within 
an inch of the symphysis to the angle was shattered. The 
zygoma was fractured in two places, and the alveolar process 
of the upper jaw w^as crushed at the roots of the first two 
molar teeth. The fragments which were loose were removed ; 
there was no bleeding from the wound, which was searched 
in vain for divided vessels ; the jagged edges were brought 
together, and water dressing was applied. 

On the evening of the 19tli, sudden arterial hsemorrhage 
came on, and about two pints of blood were lost. The 
bleeding ceased almost as suddenly as it commenced, only 
slight oozing continuing. 



442 APPENDIX OF CASES. 

20th. — Eetuin of bleeding to nearly same extent as before, 
but ceased under pressure applied to carotid. 

21st, 4 A.M. — The hfemorrhage recurred to an alarming 
extent, the patient being almost pulseless. Dr. Morgan 
proceeded to cut down upon and tie the common carotid 
artery above the omo-hyoid, meeting with considerable diffi- 
culty owing to the matting together of the tissues. There 
was no return of haemorrhage, and the ligature came away 
safely on September 3, and the patient was doing well, 
several small pieces of the jaws having come away, when, 
on the 17tli of September, he was attacked with symptoms 
of cholera, and died at midnight. 

Autojisij. — On reflecting back the soft parts from the chin, 
several fragments of the lower jaw were found loose, one 
spiculum projecting downwards, and giving rise to an external 
swelling, and another containing an incisor and bicuspid 
tooth. The zygomatic arch was fractured at both extremities. 
The lower jaw was wanting on the right side from the sym- 
physis to the ramus ; the upper jaw was fractured. 

The common carotid was found to have been obliterated 
about two inches below the bifurcation, a mass of fibro-cellular 
tissue extending from that spot to the bifurcation, through 
the upper half of which was a small tortuous canal. A clot 
extended from the point of ligature down to the bifurcation 
of the innominata, and another clot extended for three-quarters 
of an inch into the internal carotid artery. The source of the 
haemorrhage was not discovered. 

Case YL — Necrosis of nearly the whole of the Lower Jaw — 
Bemoral of the Dead Bone, including one Condyle — Bc- 
covery ivith perfect Movement of Jaw. Under the care of 

the AUTHOK. 

Egbert H., aged twenty-two, from Aylesbury, was sent to 
Mr. Heath by Mr. Ceely with necrosis of the lower jaw. 

In August, 1868, he had typhus fever in Walsall Union, 
and during the attack the face became swollen, and discharged 
both externally and into the mouth. His teeth were all 
loosened, but none were extracted. In December he was passed 
on to Aylesljury, and came under under Mr. Ceely's care. 

On February 24, 1869, patient was admitted into University 
College Hospital under Mr. Heath's care. The right side of 
the lower jaw was immensely swollen, and two inches below 
the angle was a sinus through which a probe passed up to- 
wards the base. Another sinus existed below the right canine 



EXTENSIVE NECROSIS OF LOWER JAW. 443 

tooth, and there had been a third below the left angle, 
which was now closed. The teeth were all more or less loose, 
and there were several openings in the gums, from which a 
most offensive discharge passed into the mouth. The man 
was well nourished and otherwise in good health, though he 
had when a child suffered from hip disease. On the day of 
admission, under chloroform, Mr. Heath extracted the molar 
teeth of the right side which w^ere loose, and, having divided 
the gum, extracted a very large sequestrum, comprising the 
right side of the body of the jaw from the canine tooth to the 
angle, and containing the mental foramen. The ha?niorrhage 
was very free, but was checked by plugging the shell of new 
bone from which the sequestrum was taken. The plugs were 
removed on the second day, and the mouth syringed out daily 
with disinfecting lotion. 

On March 3, 1869, under chloroform, Mr. Heath cleared 
out some small fragments of necrosed bone left in the right 
angle of the jaw, and then proceeded to remove the necrosed 
portion on the left side, which extended as far as the second 
molar tooth. Mr. Heath attempted to save the incisor teeth, 
it appearing at first that the alveolus of that part of the jaw 
was not involved. It proved, however, that the disease had 
affected the whole thickness of the Ijone, and the teeth were 
necessarily sacrificed. Upon removal of the sequestrum there 
was left a complete framework of new bone, with a deep groove 
extending from the right angle (which was quite hollowed out) 
to the second molar tooth of the left side. The mouth bled 
freely, but this was checked as before by stuffing with lint. 
The patient made a good recovery, and was able to return to 
the country in a week, the discharge having almost entirely 
ceased, and there being a deep groove in the new structures of 
the jaw from which the sequestrum had Ijeen extracted. 

On June 16, the patient returned, there being a portion of 
diseased bone on the right side. This Mr. Heath extracted, 
under cliloroform, with some difficulty, through the mouth, 
when it was found to include the angle and a great part of the 
ramus of the jaw. From this operation also the patient made 
a speedy recovery, and returned to the country, and was not 
seen again by Mr. Heath until October, when he returned with 
yet more necrosis, involving the remainder of the right ramus. 
This was removed with difficulty on October 30, and the man 
has not since suffered from pain or discharge, so that it seems 
that the whole of the dead bone has now been taken away. 

Perhaps the most singular feature in this case is the fact 



444 APPENDIX OF CASES. 

that the mau has now (December) as perfect movement of the 
jaw as if no disease had existed, notwithstanding that at the 
last operation the whole of the riglit condyle was removed en- 
tire, with about a third of the ramus. The repair has, in fact, 
been as complete as possible. When we saw the patient five 
weeks after the last operation, there was some fulness and 
prominence about the right angle of the jaw, and when the 
mouth was widely opened the lower jaw was drawn slightly 
to the right side ; but otherwise all the jaw movements 
were perfectly performed without any pain or inconvenience, 
a deep groove in the gum, reaching from the right angle to 
the second left molar, alone remaining to show the former 
seat of such extensive disease. — Medical Times and Gazette, 
Dec. 18, 1869. 

Case YII. — Abscess in the Right Upper Maxilla, commnnicating 
vjith the Antrum. By Mr. Maegetson, of Dew^sbury. 

Mrs. M., aged about forty, called to consult me about an 
enlargement of the right side of her face. 

Found a hard swelhng of the gums, extending from the 
median line to the right canine, and considerable bulging of 
the palate. She was wearing a Ijadly made partial set of 
teeth over the roots of the incisors and left canine ; the right 
canine was the only tooth left in the upper jaw\ Three years 
ago had some swelling after pain in right lateral incisor, and 
abscess formed in the socket of that tooth. Her medical 
attendant tried unsuccessfully to extract the roots. The 
swelling decreased after a time, but never disappeared 
entirely, and for the last four months it has steadily in- 
creased. She has had no pain or tenderness, and only 
feels a sort of heaviness, and is anxious about the facial 
disfigurement. 

On attempting to remove the root of the lateral incisor, it 
crumbled under the instrument. Trying a second time, and 
using a little more pressure, in order to seize the root a little 
higher, the forceps suddenly slipped uj)wards and were buried 
to the joint in a ca^'ity in the bone. A gush of thin brownish 
fluid was the result, and free bleeding from the gum ; there 
was also a discharge from the right nostril. Passing up a 
jDrobe, I found a cavity extending from the alveolus of the 
right central incisor, behind the canine, to the position of the 
first bicuspid — which had been extracted some years. At 
the posterior extremity of the roof of the cavity there was 



DISEASE OF ANTRUM T^^VOLVrN^G BRAIN. 445 

a pretty large opening into the antrum, through which the 
probe passed without meeting with any resistance. After 
satisfying myself that there was no tumour in the antrum, 
and removing a small piece of dead bone from the lower 
cavity, I syringed well with warm water, and dismissed my 
patient. 

The only treatment required, after the extraction of the 
roots, was syringing with warm water for three or four days. 
No stimulating injection was used, showing that there was no 
disease in the antrum, or alteration in the secretion from the 
lining membrane. 

Case VIII. — Disease of the Maxillari/ Antritm, involving the 
Brain. By E. S. Mair, M.D., F.R.C.S.E., Madras. 

I was first called to see Mr. J. L., aged thirty years, on the 
22nd of March, 1861. He complained then, and for some days 
pre\aously, of a copious fetid discharge from the left nostril, 
severe pain in the left cheek, extending upwards round the 
corresponding orbit. There was no swelling over any part 
of the nose or cheek ; the third molar tooth of the left side 
was loose and painful, and oozing from its side was a free 
fetid discharge the same as from the nostril. 

Suspecting these symptoms to be probably produced by 
some mischief in the maxillary antrum, the loose tooth was 
without difficulty removed, and with immediate relief. The 
discharge from the nostril disappeared, and the pain in the 
cheek and round the orbit almost entirely ceased. 

Four days afterwards (26tli) the same severe pain returned, 
but of distinctly intermittent character ; there was still no 
discharge from the nostril or tooth socket. 

On the following day (27tli) the patient had a sharp rigor, 
followed by fever, which continued for some hours, and the 
pain in the face and round the orbit continued unabated, 
notwithstanding the local application of anassthetic anodynes. 

On the evening of the 31st, Dr. J. Shaw saw the case 
with me, and suspected abscess deep in the cellular tissue 
of the upper eyelid, behind the eyeball ; an incision was 
made in the upper eyelid close under the supra-orbital 
ridge, which gave vent to a discharge of some sanguineo- 
purulent matter. 

There was immediate relief to the sense of fulness in the 
eye ; the eyeball could be moved more easily, though vision 
was not perceptibly improved. The patient slept better 



446 APPEXDIX OF CASES. 

that night than he had clone for several nights previously, 
but otherwise, on the following morning (April 1), liis 
symptoms were most unfavourable. The eyeball was enlarged 
to nearly double its natural size, and was protruding con- 
siderably forwards, while the upper eyelid was again very 
much swollen, and the lower one everted, exposing the 
chemosed conjunctiva, and leaA'ing about one-half of the eye 
itself uncovered and exposed. 

The patient complained of little pain, and remained tranquil 
up to eleven o'clock forenoon of April 2, when suddenly, 
and without a single premonitory symptom, he had a most 
violent convulsive fit, of an epileptic form and tetanic 
character. This fit, which was followed by two others of the 
same kind on the same day, was preceded by a peculiar 
scream or howl, followed immediately by rigidity of the 
whole body, opisthotonos, foaming at the mouth, and com- 
plete unconsciousness. These fits each lasted about five 
minutes, but consciousness did not return till some time after. 

This was the first indication of cerebral complication. It 
should be here noted, that prior to the first fit, in consequence 
of the great distension of the eyeball, and as no matter was 
found in the incision, which was made deep into the cellular 
tissue of the orbit, a seton was introduced into the left temple, 
and, subsequently to the fits, a cantharides blister was aj)pliecl 
to the nape of the neck. 

On April 5 the eye continued much swelled, and some 
pus escaped from the wound over the eyelid. The probe 
was again introduced to give free vent to the matter, but 
none came away. During this day the patient had a recur- 
rence of the same fits as before, and while in one of them 
the pulse flickered and fluctuated so much as to threaten 
extinction every moment. 

He continued in the same condition all the 7th and up till 
the evening of April 8, when he became completely coma- 
tose. From this he never rallied, but gradually sank, and 
died early on the morning of April 9, sixteen days after he 
first consulted me. 

The eye during the last three days of his life remained 
unchanged ; a small quantity of pus escaped from the wound 
in the eyelid, but there was little or no decrease in the 
sweUing of the globe. The discharge from the nostril ceased 
after the globe began to swell, and that from the tooth- 
socket disappeared after the tooth was extracted. 

Tlie patient had always enjoyed good health prior to his 



DISEASE OF ANTRUM INVOLVING BRAIN. 447 

last illness. He had none of the usual indications of the 
strumous diathesis, and there was no reason to suppose that 
he had any syphilitic taint in his constitution. 

Post-mortem appearances. — Head only examined. Purulent 
matter in considerable quantity flowed from the cavity of the 
arachnoid, and from between the hemispheres, on the removal 
of the falx. There was a layer of more consistent pus on 
the visceral surface of the arachnoid in some parts of both 
hemispheres, which, on removal, did not leave the arachnoid 
roughened. 

At the anterior margin of the left hemisphere, there was 
a rugged, excavated, and ulcerated surface, rather larger 
than a florin, covered with thick purulent matter, and ap- 
pearing to be the source of the pus found in the arachnoid ; 
but on turning up the anterior edge of the hemisphere from 
the roof of the orbit, there was found on its lower surface, 
about an inch from its anterior extremity, a small opening, 
with dark-coloured edges, from which a thin serous and 
discoloured fluid was exuding. This opening led to a ca^dty 
large enough to contain a good-sized walnut, lined with a 
dark-greenish, investing membrane, of at least half a line 
in thickness, which could easily be peeled off from the sur- 
rounding cerebral substance. 

The brain was now removed, and was perfectly healthy. 

On introducing the finger into the orbit, and passing it 
along its inner boundary, the latter was found diseased — 
the ethmoid bone crumbling before the finger, which passed 
readily into the upper part of the nose. Here all the 
osseous structures yielded readily to the touch of the nail, 
and portions of the ethmoid bone were removed by it with 
great facility. 

They were in a state of caries, of very fetid odour, and 
bathed in pus ; broken-down scrofulous matter on both. 

The contents of the orbit being removed, the antrum was 
opened from above, when its cavity was found filled with 
a white, soft substance of the appearance and consistence 
of firm blancmange, and also very fetid. This substance, 
subsequently examined under the microscoi^e, was found to 
consist mainly of tuberculous matter, interlaced with very 
delicate fibres, and showing an abundance of pus-cori3uscles. 
The memljrane lining the antrum was entire, considerably 
congested, and streaked with red lines. The cavity of the 
antrum did not appear to be enlarged. — Edinburgh Medical 
Jowrncd, May, 18(56. 



448 APPENDIX OF CASES. 

Case IX. — Bemoval of large Cystic-sarcoriia of Lower Jav: — 
Recovery. Under the care of the Author. 

The patient is a native of Cumberland, and has been a 
carter ever since he was eight years old. His parents are 
living and healthy. "Wlien a child he suffered from sup- 
purating glands in the neck and submaxillary region, which 
were opened : otherwise he has always enjoyed good health. 
Never had syphilis ; has lived well ; drinks beer freely ; is 
often drunk {i.e., on an average once a week). Has followed 
his occupation up to the time of admission. About six years 
ago he first noticed a small, hard swelling, about the size of a 
marble, situated in the right cheek, attached to the gum and 
lower jaw, but movable under his fingers. From the first 
it had an aching pain, dull and constant. The tumour con- 
tinued to increase in size, and four years ago it was lanced 
in the gum ; it then began to discharge, and has continued to 
do so slightly ever since. He has noticed that the discharge 
is more abundant after drinking much. It has been lanced 
twice since, and within the last six months it has been twice 
tapped by Mr. Watson, of Lancaster : the first tapping just 
before Christmas ; the second, five weeks before admission. 
JNIr. "Watson says that at each tapping about four ounces 
of fluid were drawn off. From the disi^lacement inwards 
of the two anterior molars and the second bicuspid tooth 
by the increased growth of the mass, these teeth were 
extracted two years ago. Since Christmas the tumour has 
grown with increased rapidity, and has become more tender. 
During this time the patient says he has lost a stone and a 
half in weight, and that his appetite has diminished. The 
patient cannot assign any cause for the origin of the growth. 
He has had no bad teeth in that jaw. IJemembers having 
had a blow on the jaw with a pitchfork handle before the 
tumour appeared. 

July 10, 1872. — The patient is fairly built, florid, and sun- 
burnt. He does not look ill. Tongue clean ; appetite better 
than it has been ; pulse 76, full and bounding. 

The right side of the face presents a large, smooth, globular 
swelling, which occupies the whole side. It extends in front 
to the angle of the mouth ; behind, to a distance of about an 
inch behind the lobule of the ear, measuring in this diameter 
7 1 in. Above, it extends from the tragus of the ear along 
the lower margin of the orbit to the side of the nose ; below, 
on a level with the hvoid lione. It measures from above 



LARGE CYSTIC-SARCOMA OF LOWER JAW. 449 

down, over the greatest prominence, S^ in. The circumference 
of the mass measures 18 in. The right angle of the mouth 
is drawn slightly upwards and outwards ; I )ut the contour of 
the lower lip is unaffected, and the contour of the chin quite 
preserved. The upper part of the mass is more vascular in 
appearance than the lower. On the under surface are some 
cicatrices from the abscesses which were opened when he was 
a child. The rest of the surface of the tumour is quite 
smooth, not ulcerated. Temperature of the cheek, 99-7°. The 
tumour is more tender posteriorly than elsewhere. Its lower 
two-thirds feel hard and resisting, the skin being quite 
movable over the mass. The posterior portion of the tumour 
is also solid, as well as a portion which extends in front of 
the ear for about an inch. The rest of the mass is soft and 
fluctuating, evidently containing fluid, and the upper margin 
of the solid portion can be distinctly felt across the tumour ; 
inside the mouth the alveolar border of the right side of the 
lower jaw is much widened, extending inwards, so as to 
diminish the cavity of the mouth behind the first bicuspid. 
The second bicuspid and first and second molar teeth are 
wanting. The patient says the third molar is present ; but it 
is not visible, nor can it be felt. On the widened alveolar 
border is an ulcerated surface, covered with a layer of thin 
purulent fluid, which is continually oozing. The tumour 
evidently arises from this part of the lower jaw ; for, an- 
teriorly, a thin shell of bone can be felt continuous with the 
jaw and with the surface of the tumour. The upper jaw 
does not seem to be implicated in the growth. The teeth in 
it are all present ; but the alveolar border has been displaced 
inwards from the growth of the tumour, so that the roof of the 
mouth appears contracted (fig. 93). 

July 13. — Chloroform having been administered, Mr. Heath 
proceeded to remove the tumour. He first extracted the right 
canine and second incisor teeth of the lower jaw, a piece of 
the jaw coming away with the teeth. He then made a 
vertical incision to the right of the symphysis through the 
lip down to the base of the jaw ; from the lower end of this 
incision he cut upwards and Ijack wards over the tumour 
towards the ear as far as one inch above the angle of the jaw ; 
in making this cut he divided the facial artery. Ligatures 
were applied before the incision was completed. Tlie whole 
length of the incision was about nine inches. The superficial 
tissues were then dissected off the tumour, the large upper 
flap being first raised ; and the tumour was carefully shelled 

G G 



450 APPENDIX OF CASES. 

out. In dissecting up this flap the facial artery was 
again cut and ligatured. The cyst at the upper part of the 
tumour being now fully exposed, it was laid open by a free 
incision extending right across it, and about ten ounces of 
fluid escaped. Mr. Heath then continued to separate the 
mass from the skin at tlie lower part, and, ha\dng cleared it 
as far as the anterior incision, he sawed through the jaw 
where the teeth had been extracted. He then cut through 
the mucous membrane and muscles attached to the jaw, and 
here again some vessels had to be secured. Having com- 
pletely separated the mass, he attempted to forcibly depress 
the jaw so as to disarticulate it ; but, the coronoid process 
becoming caught against the malar bone, he had to detach 
the process by the bone forceps. On depressing the jaw, he 
found that a small portion of the condyle was free from the 
growth. As he was proceeding to disarticulate, the remains 
of tlie lower jaw gave way just below the condyle, the 
tumour shelling out from the expanded bone round it. The 
posterior part of the jaw w^as left nearly down to the angle ; 
a small piece of this was afterwards cut off with the bone 
forceps. About four ligatures were applied to bleeding 
vessels, and the rest of the ha3morrhage was arrested by the 
actual cautery. The wound was then thoroughly sponged 
out and sewn up ; for the incision through the lip hare-lip 
sutures were employed, and a very fine suture for the 
mucous membrane of the lip, the rest of the incision being 
closed by silver wire sutures ; the whole of the wound was 
then painted with collodion. There was not very much 
blood lost during the operation. The patient was not 
thoroughly under the influence of chloroform the greater 
part of the time. 

After removal the tumour was almost globular in form. It 
measured 3^ inches in diameter at its widest point. It was 
slightly lobular on the surface. It weighed 13| oz. ; but at 
the upper and outer aspect was a large cyst capable of con- 
taining about oz. of fluid. The lower part of the wall of 
the cyst was bony, but the whole of the upper part was free 
from bone. The whole of the inner wall of the cyst was 
formed of a thin layer of bone. Just anterior to this large 
cyst was a smaller one containing about h oz. of thick fluid-, 
in which was a large cpiantity of cholesterine. Its walls 
were bony everywhere. Both cysts were lined by a smooth 
thin membrane. On the inner side of the tumour were two 
openings about f in. in diameter, which had opened into the 



EXTENSIVE EPITHELIOMA OF LOWER JAW. 451 

mouth. They communicated with a large cavity in the centre 
of the tumour, into which the finger couhl be pushed as far 
as the second joint. On making a section right through 
the mass, this central cavity was found to be about 2 inches 
long. The inner surface was very irregularly lobulated. 
The lobules varied in size from a pea to a filbert. They 
were covered by a smooth membrane. The tumour was 
moderately firm, of a whitish colour, and small points of 
bone were scattered through it. On scraping, it yielded a 
whitish fluid mixed with fragments of the substance of the 
tumour. Under the microscope this was found to consist 
of a few spindle cells and a vast number of free oval nuclei, 
containing one, two, or three shining nucleoli. Some of 
the nuclei were perfectly circular. The average diameter was 
about ysVu inch. 

On examining sections made from one of the lobules from 
the central cavity of the tumour, it was found to consist 
chiefly of a dense fibrous tissue, amongst which were oval 
and irregularly shaped spaces, having an appearance much 
resembling acini and ducts of glands. They were completely 
filled with oval nuclei, each containing one or more bright 
shining nucleoli. They were arranged along the walls of the 
spaces so as to look like epithelium, but they had not the 
distinct cell and nucleus characteristic of epithelium. The 
relative proportion of the spaces and fil)rous tissue varied 
greatly. At some parts it was almost firmly fibrous, and 
at others the spaces formed the greater part of the growth. 
The patient made a quick and uninterrupted recovery. — 
Lancet, March 23, 1872. 

Case X. — Case of Extensive UjntheKoma of the Lower Jaio and 
Floor of the Mouth — Removal. — Satisfactory state tivo years 
later. Under the care of the Author. 

John S., aged sixty-eight, plumber, was admitted on the 
9th of January, 1879, with epithelioma of the left lower jaw 
and contiguous mucous surfaces of the floor of the mouth and 
cheek. In the early part of October, 1878, the patient noticed 
that his three left lower molar teeth were loose, and they 
were accordingly extracted. About the beginning of Novem- 
ber he noticed, for the first time, a small sore on the left side 
of the floor of the mouth, corresponding in position to the 
teeth removed. This gradually and almost painlessly in- 
creased in size. The patient began to suffer likewise from 

G G 2 



452 APPENDIX OF CASES. 

nausea, especially in the morning. A medical man who was 
consulted ordered red wash for the mouth. Three weeks 
later he began to apply caustics, which he did six or eight 
times altogether. About a fortnight before admission the 
sore began to bleed, and continued to do so. There was no 
history or evidence of syphilis, and the patient alleged he had 
alway been healthy. He was a smoker. He did not know 
the cause of death of either of his parents, both of whom, he 
said, had lived to old age. His brothers all died at com- 
paratively early age, ascribed, by the patient, to their un- 
healthy occupation as masons. He was unable to give an 
account of the nature of their last illness. 

On admission he was a corpulent but very anaemic man, 
looking younger than his real age, and had general tremors. 
He was losing flesh, because the condition of his mouth 
allowed him to take but little food. The bowels were regular, 
and the general health fair. He suffered from sleeplessness, 
and pains about the affected side of the face of a radiating 
and lancinating kind. 

On opening the mouth an ulcerating mass of new growth 
was observed, involving the left half of the floor of the mouth 
and adjoining alveolar process of lower jaw, the surface of 
which was composed of large vascular granulations, ragged 
and covered at the posterior part with small sloughs. To the 
feel it was soft and extremely tender, extending backwards as 
far as the ascending ramus of the jaw, inwards to the middle 
line, and in front, beyond this, to the right as far as the right 
canine tooth, which was very tender when pressed upon, 
although on the outer side — i.e., between the gums and lips — 
it was not evident beyond the mid-line. The structures at 
the floor of the mouth were involved to a considerable depth, 
but the tongue was free. Externally it involved the alveolar 
process of the lower jaw on the left side, and extended to the 
junction of its gingival mucosa with that of the cheek. The 
teeth of both upper and lower jaw were discoloured ; the 
left lower molar and the right lower molars and bicuspids 
were absent. 

No enlargement of lymphatic glands could be felt in the 
neck, nor was there any induration or tenderness beneath 
the jaw. There was a sanious fetid discharge from the growth, 
and slight stomatitis. The tongue was furred, especially at 
the back, and red at the edges. 

Urine : sp. gr. 1018, neutral, high coloured, no albumen or 
sugar, 



EXTENSIVE EPITHELIOMA OF LOWER JAW. 453 

The heart and lungs were healthy. Neither spleen nor liver 
was enlarged. 

On January 22, at 3 P.M., the patient was put under the 
influence of chloroform, and Mr. Heath extracted the right 
lateral incisor tooth, and then cut through the lip and soft 
structures down to the lower border of the jaw. The jaw 
was then sawn through at the point where the tooth had lieen 
extracted. A string was now passed through the tongue by 
which that organ might be drawn out if necessary in case of 
impediment to breathing (which did occur once or twice 
during the operation). Mr. Heath next divided the structures 
beneath the lower border of the jaw, beginning at the lower 
end of his first incision, and ending just in front of angle of 
jaw, the facial artery being secured by hare-lip pin ligature. 
Turning back the cheek flap the jaw was sawn through about 
an inch and a half in front of the angle, and the piece of bone 
included between the two saw-cuts, together with the greater 
part of the growth attached, removed by dividing the soft 
parts of floor of mouth attached to it. At this stage much 
hemorrhage occurred, chiefly from the lingual artery and its 
branches, which were all ligatured. The dental foramen in the 
portion of jaw left Ijehind having been closed with a spigot of 
wood, the remainder of the growth was dissected off the flap. 
The parts were then mopped out with a strong solution of 
chloride of zinc ; all suspicious particles removed ; the flap 
was brought down and secured by four or five fine wire 
sutures, two hare-lip pins and twisted sutures being employed 
to secure the lip, with an additional suture of fine silk at the 
upper part at the verge of its mucosa. At the posterior part 
of the wound a small opening was left, through which the 
end of the ligature applied to the facial artery was allowed 
to protrude, acting instead of a drainage-tube. The edges of 
the wound were finally painted over with collodion, and 
covered with dry lint, and the patient put to bed. The string 
in the tongue was allowed to remain, and kept out of the 
mouth in case its use should become necessary. 

On examining the growth removed it presented all the 
naked-eye appearance of an ulcerating epithelioma, involving 
the alveolar process as far back as the last molar tooth, while 
forwards it was co-extensive with the excision. It spread 
outwards to the adjacent part of the cheek, but involved 
only the mucosa, and not the deeper structures. Inwards it 
reached along the floor of the mouth as far as mid-line. The 
tongue was not involved. The posterior section of the face 



454 APPENDIX OF CASES. 

showed two questionable-looking spots of probably an exten- 
sion of the growth. 

The patient's pulse became irregular and feeble after the 
operation, and he appeared somewhat collapsed ; but brandy 
was administered, and he had ice to suck. There was little 
trouble with the tongue, and he slept well during the night. 
Next morniug the pulse was still feeble, but regular, and the 
patient seemed to l»e in good spirits. 

On the -Ziih, patient complained of headache. He had 
slept fau'ly during the night. The pulse was very weak, 9^ ; 
temperature 99" ; respiration 24. As he had not taken his 
food well, an enema of beef-tea and brandy and eggs (of each 
one ounce) was administered. The mouth was carefully 
washed out with a good quantity of warm solution of Condy's 
fluid lotion. Discharge not very offensive. 

On the 25th he had slept fairly well. He complained of 
pains in the lower lip and up the left side of the face. Tlie 
pulse was still very weak, 92 ; temperature 99°. The parts 
were well syringed out. 

On the 27th the patient was looking quite bright. The 
parts were doing very well. The sawn surfaces of the bone 
could be seen covered with granulations. 

On the 29th the temperature was normal, and the patient 
had thoroughly recovered from the effects of the operation. 
The discharge from the mouth drained through the lower 
opening, and was only slightly offensive. 

From this time the patient made a rapid and steady re- 
covery, and was discharged on February 21 to go to East- 
bourne. He returned in March with the mouth quite healed. 
In November, 1880, the patient visited the hospital in per- 
fect health, having grown stout and strong for his age. The 
mouth was perfectly sound, the gap in the jaw being tilled by 
firm, dense cicatrix, covered with healthy mucous membrane, 
the right side of the jaw being drawn inwards by the action 
of the muscles, as is usual in cases of division of the 
mandible. — L ancet. 

Case XI. — Epithelionuc of the Antrum — Pneumonia — Death. 
Under the care of the Ai'THOK. 

li. M., aged fifty-nine, a shoemaker, was admitted on 
May 30, 1879. At the beginning of the previous month 
he had noticed that his right nostril was obstructed ; a week 
or two afterwards the lower lid of the right eye became 



EPITHELIOMA OF THE ANTRUM. 455 

inflamed, and a swelling which commenced here rapidly 
extended over the right cheek. About this time a painful 
swelling of the hard palate appeared, and the patient con- 
sulted a dentist, who extracted a tooth. Shortly afterwards 
he applied at the hospital. His brother was stated to have 
died of cancer of the kidney. The other members of his 
family were, so far as he knew, healthy. 

He was a pale but well-nourished and well-preserved man 
for his nge, though he had, he stated, lost flesh latterly. 
Temperature varied from 99° to 100° ¥. He complained of 
a feeling of stutflness in his jaw, but of no pain. 

The skin of the right side of the face was reddened, 
cedematous, and tender, and the cheek was projected out- 
wards by the tumour beneath it. The right eyelids were 
closed and cedematous, but could be opened slightly, dis- 
playing chemosis of the conjunctiva, a clear cornea, and a 
somewhat sluggish iris. The right nostril was obstructed, 
and there was a purulent discharge from it ; the nasal duct 
on the right side also appeared to be obstructed, giving rise 
to overflow^ of tears. To the touch the tumour gave the idea 
of a soft solid rather than of fluid. Most of the right half of 
the hard palate was absorbed, a soft elastic swelling occupy- 
ing the roof of the mouth, the mucous membrane of the 
latter being congested and swollen. The teeth of the upper 
jaw were carious or absent, but the alveolar process was 
neither displaced nor softened. Owing to the resistance of 
the patient, an examination of the posterior nares could not 
be made. The lymphatic glands in the posterior triangle of 
the neck were enlarged, but free from tenderness. The 
mouth could not be opened to its full extent, and speech 
was slightly aflected. The tongue was broad, pale^ and 
marked by the teeth. 

On the 31st a tine trocar with canula was inserted into the 
swelling on the roof of the mouth, and a few drops of stink- 
ing pus evacuated. The opening made by the trocar was 
subsequently enlarged, and a drainage-tube was passed into 
the antrum. 

It soon became evident that the growth was malignant, 
and as the man's condition became worse daily, removal of 
the upper jaw offered the only chance of prolonging his life. 
This was accordingly done on June 4. The floor of the 
orbit was taken away, but it was impracticable to wholly 
extirpate the growth in this direction, as the orbital struc- 
tures were infiltrated The somewhat free bleeding was 



456 APPENDIX OF CASES. 

restrained hj the actual cautery, and the cavity of the wound 
was stufied with strips of lint soaked in a strong solution of 
chloride of zinc. 

The growth appeared to have commenced in the antrum, 
the walls of the latter being partially absorbed, the anterior 
almost wholly, thereby allowing invasion of the orbit, the 
mouth, and the pharynx. Several pieces of dead bone, 
surrounded by offensive pus and debris of broken-down 
growth, were found in its cavity, thus accounting for the 
inflammatory condition of the superjacent skin, and the 
purulent discharge from the mouth and nostrils. In other 
parts the growth was of a yellowish colour, translucent, 
gelatinous, and vascular. Several ordinary soft gelatinous 
polypi were extracted from the right nostril during the 
operation. 

In sections taken from the margin of the growth near the 
gum, the microscope showed cylinders of epithelium cells, 
irregular in form and sinuous in outline, sometimes anas- 
tomosing, set in a stroma made up of fibrous tissue and 
spindle-shaped cells. Epithelium " nests" were observed 
here and there, but these were few, small, and ill- developed. 
The papillpe of the mucous membrane covering the gum, 
where the latter was infiltrated, were hypertrophied. The 
histological characters of the growth appeared to correspond 
with those of the " epitheliome tubule " of Cornil and 
Eanvier. 

On June 1 3 pneumonia was present at the base of the 
right lung, and on the following day friction sounds were 
audible over the affected area. The edges of the skin wound 
had united, except at the inner angle of the orbit. 

On the 16th there were dulness, extremely weak breath 
sounds, diminished vocal fremitus, and resonance to the 
angle of the right scapula, with bronchial respiration above. 
The lymphatic glands, which had l)ecome larger and very 
tender in the right posterior triangle, had diminished in size 
after treatment with belladonna and poulticing. 

On the 18th the physical signs of pneumonia at the left 
base became e\ddent, and the general condition of the patient 
worse, though he wanted to " be up and about." The foetor 
from the cavity of the wound was now almost intolerable, 
and one or two sloughs had separated. 

From this time the chest symptoms increased in severity, 
and he died on June 26. 

Necro2Jsy (by Mr. Baeker) tiventy-five hours after dcath.''^— 



EPITHELIOMA OF THE ANTRUM. 457 

Eigor mortis well marked. Body well nourished. The 
serum in the pericardium was normal in amount and 
characters. The heart was somewhat enlarged, and rigor 
mortis was well marked ; a good deal of fat was noticed, 
chiefly on the anterior surface. The superficial veins were 
somewhat loaded. The right auricle contained firm post- 
mortem clot. The right ventricle was also engorged with 
clot, part of this having evidently formed during several 
hours before death. The left ventricle was firmly contracted, 
and contained a small quantity of tough coagulum. The 
cardiac valves were healthy. The left lung was extremely 
emphysematous anteriorly, and posteriorly it was covered 
with recent lymph, hardly adherent. There were six ounces 
of serum in the left pleural cavity. The inferior lobe was 
considerably congested, and some small portions were 
collapsed. Section showed general congestion, and grey 
hepatization with softening at numerous points, but the lung 
was not gangrenous. The bronchi were intensely congested 
in patches down to the small ramifications, and full of dirty 
brown sero-mucous fluid. The right lung was adherent to 
a large extent of the ribs, particularly over the lower lobe, 
and by more recent lymph al)ove. A large abscess opened 
on removing lower lobe from chest wall. This abscess, 
occupying a large portion of lower border of upper lobe, 
upper border of lower lobe, and extending deeply into the 
substance of the lung, was a ragged, ill-defined space, full 
of black, very fetid, broken-down lung tissue, and was sur- 
rounded by blackened, sloughing, very soft lung tissue. 
The bronchi, as in the left lung, were intensely congested, 
increasingly so towards the finer ramifications, and full of 
foul sero-pus. The bronchial glands were much enlarged at 
root of both lungs. The tongue was covered with a thick 
covering of foul material, apparently dropping down from 
the roof of the mouth. There were enlarged papilla? at the 
base, the size of millet seeds, raised, pedunculated, and deeply 
pigmented. The cesophagus was normal. The mucous mem- 
brane of the larynx and trachea was inflamed throughout. 
There was a quantity of grey mucus in the ventricles of the 
larynx. The anterior surface of hard and soft palate was 
covered with foul, tenacious pus. The operation cavity ex- 
tended back beyond orbit to the pterygoid fossa and upwards 
to sx-)henoid bone. The septum of the nose was carious, and 
giving way. The orbit and eyeball had not been particu- 
larly injured by the operation. The liver was apparently 



458 APPENDIX OF CASES. 

normal. There was no post-mortem staining in the great 
vessels, nor extravasation in the mncous membrane of the 
intestines. — Lancet. 

Case XII. — Large Osteosarcoma of the Lower Jaio — Removal 
— Death. Under the care of the Author. 

W. T., aged thirty-two, was admitted into University 
College Hospital, Nov. 13, 1 867, with an enormons tumour 
of the lower jaw. About eleven years before he had a severe 
pain in the right jaw reseml)ling toothache, and after some 
little time he perceived a small hard swelling about the size 
of a nut just below the right canine tooth, which was not 
decayed, nor were any of the teeth in its immediate vicinity 
diseased. This swellinfr continued about the same size for 
five or six years, during the latter part of which time it was 
entirely free from pain. Four years ago it began to enlarge, 
and two years afterwards he was thrown from a cart and fell 
on his face, when he had profuse bleeding from the gums. 
The tumour now grew rapidly, spreading along its anterior 
surface, and involving the whole of the right side of the jaw. 
About twelve months ago it began to involve the left side of 
the jaw, and extended up to the angle. He had been seen by 
various medical men at his native place, and also by one 
London hospital surgeon, and the question of an operation 
had been discussed, but nothing had been done. Two years 
before, one quack burnt the inside of his mouth with acid, and 
another put a white ointment upon the surface of the tumour, 
which caused the skin to give way at the point where the 
protrusion appeared. About a year before admission, the 
portion of the tumour near the right angle of the jaw rapidly 
increased, and in a short time the skin gave way, and a 
quantity of offensive pus was discharged, but there was no 
diminution in the swelling. Latterly, owing to the difticulty 
in swallowing, he had been able to take little but milk and 
brandy, and this in small quantities at a time, so that he 
had become much reduced in strength. His family had all 
been healthy and long-lived. 

On admission, the patient presented an extraordinary 
appearance, the mouth and all the lower part of the face being 
occupied by an enormous tumour. The measurements of this 
were as follows :• — Lrom the lobule of one ear round the chin 
to the lobule of the other ear, 19|- inches; from the border 
of the lower lip across the chin to the pomum Adami, 13 



LARGE OSTEO-SARCOMA OP LOWER JAW. 459 

inches ; from the angle of the jaw across to the same point 
on the opposite side, 14 inches. When the man was sitting 
the tumour rested upon the top of the sternum ; l^ut it moved 
freely when he opened and closed the mouth. Between the lips, 
of which the lower was much stretched, so that the circum- 
ference of the mouth measured 9^ inches, there was a red, 
granulating mass of disease, which came in contact with the 
upper lip ; but when the mouth was opened^ a space inter- 
vened through which a second mass, covered with the mucous 
membrane of the floor of the mouth, could be seen almost in 
contact with the roof of the cavity, and completely hiding the 
tongue. Between these two masses some of the teeth could 
be felt and seen. Fig. 161, taken from a photograph, shows 
the patient with his mouth shut. From beneath the cheek 
on the right side a foul, yellowish discharge constantly exuded. 
An inch below the lower lip was a large red, fungous mass 
covered with healthy granulations ; this extended to the lower 
border of the tumour, and the skin was adherent around it. 
On the right side, just below the angle of the jaw, there was 
another smaller fungous projection ; but the skin on the left 
side was perfectly healthy, though much stretched. The 
right ramus of the jaw could not l^e defined, though the angle, 
could be distinctly perceived. The articulation, however, was 
not involved. The tumour, though overlying the neck, in no 
degree involved its tissues, and there were no enlarged glands 
either below the jaw or in the neck. On the left side the 
whole of the ramus and angle could Ije clearly made out, the 
disease stopping short of the latter point. 

From the time of his admission the patient was well fed 
with strong beef-tea, milk, eggs, and brandy ; and consider- 
ably improved in appearance. Mr. Heath's colleagues 
agreeing with him as to the advisability of an operation, this 
was undertaken on Nov. 20, 1867. The patient being 
seated in a chair, Mr. Clover administered chloroform at first 
with the ordinary mask, and during the operation with a 
smaller one, enclosing only the nose. As soon as the patient 
became partially unconscious he was carefully secured in the 
chair with bandages, and his head was held firmly against 
the breast of an assistant. Perfect aniesthesia having been 
induced, Mr. Heath, standing on the right hand of the patient, 
divided the lower lip in the median line, and carried the 
incision round the right side of the fungous protrusion to 
the lower extremity of the tumour. The skin was then 
rapidly dissected back with the assistance of Mr. Marshall, 



460 APPENDIX OF CASES. 

who took up the vessels of tlie flap. Eeturning to the 
middle line, Mr. Heath made a second incision on the left 
side of the fungus, meeting the former one alcove and below, 
and dissected back the skin off the tumour, as far as the jaw. 
The bone being isolated with the assistance of Mr. Erichsen, 
the second molar tooth was drawn, and a narrow saw applied 
at that point ; but before complete division was effected the 
weight of the tumour caused it to break away. As had been 
pre-arranged, Sir H. Thompson then grasped the tongue, 
which was now seen for the first time, and transfixed the tip 
with a stout needle and ligature, by which it was held until 
the operation was concluded. On dividing the mucous mem- 
brane beneath the tongue, a large lobulated mass came into 
view imbedded among the sublingual muscles ; and this 
being dragged forward, the muscles were divided close to the 
tumour, and one or two bleeding vessels were promptly 
secured by Mr. B. Hill. The tumour being then turned over 
to the right side, Mr. Heath carried the knife upwards, so as 
to clear the coronoid process, which was healthy ; but this 
appeared to be driven forward against the malar bone, 
and tightly jammed, so that forcil^le traction made on the 
tumour failed to clear it. Grasping the process itself with 
the lion forceps, Mr. Heath succeeded, however, in wrenching 
it out, when the condyle of the jaw, also healthy, immediately 
came forward without any dissection. A little dissection 
round the posterior margin of the tumour now completely 
disconnected it, and it was removed. About half a dozen 
bleeding vessels were now tied, none of them of large size, 
the two facial arteries having been preserved uncut. Finding 
the bone on the left side where the tumour had broken away 
rough and irregular, Mr. Heath sawed it cleanly through, 
close in front of the wisdom tooth. 

There was now an enormous gap ; the fauces, tongue, and 
front of the larynx Ijeing fully exposed, and the flap of skin 
on each side being pendulous and superabundant. The right 
was somewhat ragged, owing to the perforation which had 
taken place, and also owing to its being so adherent to the 
tumour that it had been perforated at one or two points ; Mr. 
Heath therefore removed a portion of it, adapting the 
opposite flap to it. The lip was then brought together with 
three hare-lip pins and a twisted suture, and the remainder 
of the incision was held together with four silver sutures, 
placed some distance apart so as to allow discharge to escape. 
The thread holding the tongue was next secured to the hare- 



LARGE OSTEO-SARCOMA OF LOWER JAW. 461 

lip pins, so as to bring the apex of it close to the lip ; and 
some lint was placed in the large cavity, and a bandage 
externally, so as to check oozing and maintain the shape of 
the part. The patient was then carried to bed. Not more 
than three ounces of blood were lost. 

Half an hour after the operation the patient had some 
brandy by the mouth, and one-third of a grain of morphia 
was injected beneath the skin. He dozed during the after- 
noon, but was well supplied with beef-tea and brandy both 
by the mouth and per rectum. He had a second dose of 
morphia at night, and got some sleep, being warm and 
comfortable, and with a fair pulse. 

On the two following days the patient's condition was as 
comfortable as could have been hoped for ; he took plenty of 
nourishment and stimulants by the mouth, and also had 
nutrient enemata. 

On the evening of the third day his breathing and pulse be- 
came more rapid, and he had a slight rigor. Mr. Heath now 
removed the ligature holding the tongue, which was giving 
him some inconvenience, and ordered him quinine in ten- 
grain doses. 

On the 23rd his condition was more satisfactory again. The 
pledgets of lint in the chin were removed, and the wound 
well washed out with Condy's fluid. He passed a comfortable 
day, and on Sunday (fifth day) he was apparently gaining 
ground, and was well enough to write his want of some stout 
upon a slate, and took plenty of nourishment. In the even- 
ing, however, he suddenly became worse, the pulse failing 
and the skin becoming cold ; and notwithstanding the most 
solicitous attention on the part of the house-surgeon, Mr. 
Shoppee, he died early on Monday morning (sixth day). 

At a post-mortem examination, all the viscera were found 
healthy, and there was no evidence of py?emia. The wound 
had so contracted that the outline of the face was quite 
restored. The skin at one point was a little discoloured, as 
by a bruise. 

The tumour weighed 4 lb. 6 oz., and was a good example of 
fibro-cellular growth, springing up between and expanding the 
plates of the lower jaw. The disease extended from the junc- 
tion of the body with the ramus of the left side to half-way 
up the ramus of the right side. The right condyle was 
perfectly healthy, and the coronoid process had been broken 
off in the operation. Mr. Heath showed the preparation at 
the Pathological Society on Dec. 3, and a wax model of it in 



462 APPENDIX OF CASES. 

the recent state has been j^laced in the Museum of University 
College. — Lancet, Dec. 21, 1S67. 

Case XIII. — Case of Symmetrical Enlargement of hoth sides 
of the Zoicdr Jaw — (Myeloid .?) Under the care of the 
Author. 

William Henry Hogan, aged seven and a half, was brought 
to me, Feb. 12, 1867, by Mr. C. J. Fox, with remarkable 
enlargement of both sides of the lower jaw. When a year 
and a half old the mother first noticed an enlargement, first 
of one side (right ?), and then of both, which has been 
gradually increasing. He has never complained of any pain, 
but had a good deal of difficulty with his teeth. He was 
rickety in his legs, and was at Ormond Street Hospital for 
some time. 

He is now a well-nourished boy, with a remarkably broad 
face, due to the symmetrical development of a tumour on 
each side of the lower jaw, involving the posterior half of the 
body on each side. The tumours are smooth on the outer 
and lower part, but slightly nodulated at the upper. Within 
the mouth they come up to the level of, but do not encroach 
upon, the teeth. He has cut his permanent first molars and 
incisors. The temporary canines and molars are still present, 
and somewhat decayed. 

April 3. — He came to University College Hospital. Ordered 
ung. iodin. co. to apply to one side. The boy attended for a 
short time at the hospital without improvement, and then 
ceased to come. 

In September I saw him, and found that both tumours had 
considerably increased, and I persuaded his parents to send 
him into the hospital, where he was admitted on Sept. 9, 1 867. 
A photogTaph and cast were now taken (fig. 170). 

Opercdion, Sept. 11. — I made an incision over the right or 
larger tumour, and having divided and tied the facial artery, 
exposed and scraped the periosteum off the tumour. It was 
bony externally, but felt spongy on pressure. With a narrow 
saw I then removed the most prominent portion, which cut 
very easily ; then a second slice, and afterwards, with the 
bone forceps and gouge, removed as much of the semi- 
cartilaginous structure as I could without interfering with the 
teeth or opening the mucous membrane. As the surface of 
the bone bled freely, it was touched lightly with the cautery, 
and the wound was filled with lint. The growth appeared to 



MEDULLARY SARCOMA OF LOWER JAW. 463 

be an enchondroma, expanding the outer plate and under- 
going ossification, but is pronounced myeloid by Mr. Bruce. 
The inner plate of the jaw was perfectly even, and at the end 
of the operation not more than the normal thickness of jaw 
remained, 

Tlie wound suppurated healthily, and soon contracted, the 
boy being about again in a few days. 

Oct. 2. — I removed the growth on the left side in the same 
manner as before. This growth appeared of precisely the 
same character as the other. The boy made a rapid recovery, 
and was discharged with the wounds nearly healed on 
Oct. 10. 

The boy came to me in December quite well, and a second 
photograph (fig. 171) was then taken. He continues well at 
the present time. 

Case XIV. — Medullary Sarcoma of Lower Jaw in a Cliilcl — 
Two successful Operations — Return of the Disease — Death. 
Under the care of the Author. 

Miss M. E., aged five, was sent to me by Mr. Edward 
Eandall, of Finsbury Square, on Sept. 9, J 867, with a tumour 
of the lower jaw. She was the tenth of a family of eleven 
healthy children, and her parents are strong and robust. She 
was fat and well-nourished, though thinner than she had 
been, and in good health until the last week in July (seven 
weeks before), when her mother noticed that the second 
temporary molar tooth on the right side was raised above the 
others, and the gums looked swollen. Her mother took out 
the tooth, which was quite loose : but the swelling increased, 
and the first permanent molar became loose, and was extracted 
by Mr. Cole, of Ipswich. She was under the care of Mr. 
Mumford, of Ipswich, who used nitrate of silver lotion with- 
out benefit, since the growth continued to increase rapidly, so 
that she has been unable to eat solid food for a fortnight. 

The whole of the lower jaw on the right side was con- 
sidtu'ably enlarged, and on opening the mouth, a large, 
irregidar, reddish mass was seen filling up all the cheek on 
the right side, the extent of which it was impossible to 
define. The tumour had a semi-elastic feel, and there were 
apparently no enlarged glands. There could be no question 
as to the propriety of, and necessity for, immediate operative 
interference, which I arranged to undertake on the following 
day. 



464 APPENDIX OF CASES. 

On Sept. 10, 18G7, the patient being under the influence 
of chloroform, I got my finger into the mouth, and then 
ascertained that the jaw was completely involved in the 
tumour, the elastic feeling being communicated through the 
bone. I divided the lower lip in the median line, and carried 
the incision round the border of the tumour to the level of 
the lobule of the ear. I then dissected l)ack the flaps, and 
having divided the facial artery, tied it. Having extracted 
a loose tooth, I then sawed through the jaw immediately to 
the right of the symphysis, and detached the tissue on the 
inner side. On making traction, the tumour came away, 
leaving a rough irregular piece of the jaw and a small portion 
of the tumour Ijehind. These I subsequently extracted, 
including the condyle and coronoid process, which latter 
broke off' and was removed separately. The internal maxillary 
artery was not wounded, and there was no great hasmorrhage, 
four ligatures being applied and cut short. The lij) was 
brought together with two hare-lip pins, and the remainder 
of the wound closed l.)y wire sutures, a silk suture being put 
in the red of the lip. Collodion was painted over all. No 
further dressing was applied. The child rallied, and took 
some brandy-and-water. In the afternoon she was quite 
comfortable and the pulse was good. There was a little 
oozing from the wound. In the evening she had had some 
sleep, and had taken a little soup. She drank water fre- 
quently. There was no bleeding. The tumour proved to be 
of soft consistence, and had destroyed all the body of the 
jaw, and a portion of the ramus ; the condyle, coronoid 
process, and upper portion of the ramus being healthy. The 
point of section of the bone was healthy, and close to it 
were the canine and first temporary molar. In the upper and 
posterior part of the growth was the crown of the second 
permanent molar, carried quite out of position. To the naked 
eye the tumour presented a loose fibroid appearance. Mr. 
Bruce kindly examined a portion microscopically for me, and 
reported numerous fibres, with here and there development of 
cells, seemingly medullary. 

Sept. 11. — She had had a comfortable night. The mouth 
syringed out with Condy's fluid three times. The child took 
some milk and soup, and was quite comfortable all day. 

13. — Child quite comfortable and happy, and takes liquid 
food well. I removed the hare-lip pins. 

14. — I removed the sutures. The wound was healed except 
at the junction of the vertical with the horizontal incision, 



MEDULLARY SARCOMA OF LOWER JAW. 465 

where tliere is a minute opening. The patient to be dressed 
and get up to-morrow. 

23. — She went home to the country quite well, with the 
exception of one spot at the angle of the cicatrix, which still 
discharged slightly. 

Oct. 31. — I heard that slie was quite well. 

26. — The child was brought to town on account of a return 
of the growth. The mother says she first noticed something 
wrong on the 22nd, when there was a small lump in the mouth. 
This grew very rapidly, and Mr. IMumford advised her coming 
up at once. 

I found a mass within the mouth on the right side, nearly 
as large, and of precisely the same appearance, as the former 
growth. It involved a portion of the jaw left, and ex- 
tended to the canine tooth on the left side, the incisors 
being loose. The cicatrix was sound except at the junction 
of the vertical with the horizontal incision, where the skin 
was ulcerated and there was a fungous protrusion of the 
size of a cherry. I explained the serious nature of the case 
to the parents, and said that an immediate operation was 
the only hope, as, if left, the growth would rapidly fungate 
and destroy the child, and they consented to the operation 
proposed. 

On Oct. 27, 1867, I divided the lip and opened up the old 
cicatrix to a great extent, surrounding, however, the portion 
involved in the fungus. I then dissected back the flap, and 
found the growth extended tt) what would have been half way 
up the ramus. I isolated it, and then dissected back the left 
half of the lip. I next removed the first molar, and sawed 
the jaw close in front of the second molar. Having put a 
string in the tongue for safety, I then divided the sublingual 
muscles, and got the growth and j)iece of jaw away entire. 
Two or three large vessels were tied, principally under the 
tongue, and a few small ones. I washed the entire wound 
carefully with a solution of chloride of zinc (forty grains to 
the ounce), brought the lip together with two hare-lip pins, 
and the remainder of the wound with sutures, and then 
fastened the string attached to the tongue to the upper pin in 
the lip. The child bore the operation very well. In the 
evening she was cold and restless, but rallied with the use of 
hot bottles and a little brandy. 

Oct. 28. — Patient had had a good night, and was asleep 
when I saw her at nine o'clock, and warm and comfortable. 
She passed a quiet day, taking a good deal of milk and a 

H H 



466 APPEN^DIX OF CASES. 

little wine. She was a little distressed by the ligature in the 
tongue. 

31, — I removed the hare-lip pins and three of the stitches, 
leaving those near the angle of the wound for the present. A 
little pus was pent up in the upper part of the old cicatrix, 
which I evacuated. 

Nov. 1. — I removed the remaining stitches. The wound 
was healing well, except at the point where the skin was 
implicated and removed, and there it gaped. 

3. — The child was up and dressed. She was able to close 
her lips and move her tongue very satisfactorily. She takes 
her food fairly, and has sucked a chicken-bone. 

She continued to improve rapidly, and by the 10th, when 
she returned to the country, the wound was perfectly healed 
with the exception of a small spot where the portion of skin 
had been removed. She had perfect control over her tongue 
and lips, and could move the tissues of the chin very satis- 
factorily. There was no appearance of any return of the 
growth at this date. 

Dec. 16. — I heard from the father that the child was per- 
fectly well, and that there was no appearance of return of 
the growth. He sent me her photograph, from which tig. 17-i 
was taken, to show how little deformity resulted from the 
double operation. 

On Jan. 8, 1868, I heard from Mr. Mumford that the 
disease had reappeared at the symphysis, and also in the 
masseteric region on both sides, there being loss of appetite, 
exhaustion, and general irritability of system. The poor 
little patient lingered for a month, and died on Feb. 9, just 
five months after I first saw her. 

Case XV. — Epithelioma of the Tongue, involving the Lower 
Jaw — Removal of the Groivth and three inches of the Lower 
Jaw — Recovery. Under the care of the Author. 

E. J., aged fifty-two^ was admitted Sept. 21, 1875. 
He was unable to move his tongue, and saliva trickled down 
his chin ; articulation was very indistinct ; he was quite 
unable to chew, but could swallow fluids readily ; the breath 
was very offensive. The front teeth of both jaws were 
worn down and decayed, and all the teeth in the lower jaw 
were very loose. The gums on the left side of the lower jaw 
were swollen, thickened, and irregular, the surface being 
covered with firm, solid granulations ; this tissue extended 



EPITHELIOMA OF THE TONGUE. 467 

between the teeth, into the floor of the mouth, and to the 
tip of the tongue, which was iixecl to the lower jaw, being 
blended with this growth on the gums. The growth in the 
gums did not extend beyond the middle line. Under the 
right angle of the jaw there was one enlarged hard gland ; 
on the left side there was a mass of hard tender glands. 
The patient complained of j^ain in the lower jaw, and of a 
very severe shooting pain and tenderness in the occipital 
region. This latter pain was so severe as to make him 
writhe in great agony at times. The patient was thin, looked 
worn out with pain, and expressed himself willing to undergo 
any operation for relief. The history he gave was that in 
January, 1874, he noticed one of the glands, under the jaw 
on the right side Liecome tender and swollen, and a few days 
after a sore appeared under the left side of the tongue, which 
soon went away; he also had an ulcerated throat at this 
time. The gland was painted with iodine, and became con- 
siderably smaller and ceased to trouble him, but in September 
following it swelled again and broke, discharging pus. About 
this time (twelve months before admission) he noticed diffi- 
culty in articulation, his tongue being stiff ; this rapidly got 
worse, and at Easter, 1875, his tongue was quite fixed to the 
jaw. He then went into St. Bartholomew's Hospital, where a 
part of the tongue was removed, which greatly relieved him 
for a time, but he soon began to get worse again, and then 
was sent into University College Hospital. He stated that 
he had been a great smoker, generally using a clay pipe. He 
had been quite unable to take solid food for a year before 
admission. Xo history of syphilis, tubercle, or cancer. He 
was ordered spoon diet, four eggs, and four ounces of brandy. 
Hypodermic injections of morphia were given for relief of jjain. 
On September 29 Mr. Heath proceeded to operate. The 
patient was placed under chloroform, and the incisor canine, 
and first bicuspid teeth were extracted ; two pairs of clamp 
forceps were apphed to the under lip about three inches 
apart, so as to compress the coronary vessels, and a vertical 
incision along the middle line was made down the lip and 
continued to the hyoid bone ; the healthy integuments were 
dissected back from the jaw on each side, and the l)one was 
sawn through on each side an inch and a half from the 
sjinphysis. The wire of the galvanic ecraseur was then 
applied round the mass thus loosened, which was drawn 
forwards by vulsellum forceps, and included nearly the whole 
of the tongue and all the sublingual tissues. For eight 

H H 2 



468 APPENDIX OF CA.SES. 

minutes a low current was passed, which was then increased 
a little, the whole process occupying twelve minutes. A 
piece of whipcord was passed through the stump of the 
tongue, which was gently drawn forwards and sponged with 
perchloride of iron. The edges of the wound were then 
brought together by three hare-lip sutures, and a fine silk 
thread through the mucous membrane. The lower part of 
the wound was left open to serve as a drain ; the whipcord 
ligature was fastened to one of the pins to prevent the tongue 
falling back. A hypodermic injection of one-quarter of a 
grain of morphia was given, and the patient was then carried 
back to bed. 

The patient passed a good night, sleeping a great deal. 
At 4 A.M and at 7.30 a.m., an enema of egg, beef-tea, and 
brandy was administered. A good deal of saliva and blood- 
stained serum escaped through the opening into the floor of 
the mouth. ISText morning the temperature was 99°; pulse 
72, regular, and fairly strong ; he said that the pain at the 
back of the head was less. He was fed through a catheter 
passed into the oesophagus every two hours during the day, and 
had two nutrient enemata at night, but afterwards he was 
fed only every four hours, taking six ounces of brandy in the 
twenty-four hours. He complained of a painful swelling 
under each angle of the jaw. 

On October 1 a swelling as large as half an orange was 
noticed over the manubrium ; it pitted on pressure, had a 
distinct edge, not tender, and was movable over the bone. 
The tongue was unfastened from the lip, but the whipcord 
was left in the tongue for a few days longer, to enable the 
patient to draw it forward when he was fed and whenever 
he felt a choking, which usually came on when he lay down. 
At night, as he was found to be weaker, brandy was increased 
to nine ounces. On Oct 3 the two upper pins were removed 
from the lip, and strapping applied across the jaw and lip. 
The stump of the tongue was covered by a black eschar, and 
on the tonsils and anterior pillars of the palate was a white 
exudation. There was a free discharge of saliva and turbid 
foul-smelling fluid through the drain under the chin ; the 
patient wore an oakum bib to catch this. There was con- 
siderable swelling on each side of the neck below the jaw, 
and the swelling was tender and very painful. The mouth 
was washed out with Condy's fluid several times a day, and 
the sloughs painted with glycerine of carbolic acid. Next 
day the lowest pin was removed, and the incision in the lip 



EPITHELIOMA OF THE TONGUE. 469 

was found to be entirely healed, except at the lowest part, 
which was purposely left open. 

Oct. 4. — Temperature 98-5°; pulse 80, much stronger. 
The swelling over the sternum had almost entirely disap- 
peared. The pain in the head was as bad as ever. 

For the next week the patient slowly improved ; the slough 
and exudation cleared off the tongue and mouth ; the swelling 
in the neck gradually subsided and became less, as did also 
the pain in the head ; the temperature was not above the 
normal. As the Condy's fluid failed to keep the mouth sweet, 
it was syringed out with a dilute solution of terebeue, which 
was followed by a most marked improvement in this respect. 
After the 4th the nutrient enemata were discontinued. 

On Oct. 1 1 it is noted that he was better, with less pain 
in throat and head, and that he looked more cheerful ; the 
whole of the stump of the tongue was free from slough ; a 
little slough was still adherent to the surfaces of the bone ; 
the ends of the bone had approximated a good deal, and on 
the 15th were only half an inch apart. After Oct. 16 the 
pain in the head disappeared, and only very occasionally 
returned slightly ; he began to pick up his strength fast, 
slept well, was cheerful, but complained of pain behind the 
thyroid cartilage when the catheter was passed ; pressure 
over the thyroid also gave pain, and a hard tender lump 
under each angle of the jaw troubled him. He had poultices 
applied to these on Oct. 20, which relieved him very much, 
so that on the 26th it was noted that no lump was to be felt 
on either side, and that he was quite free from pain except in 
the pharynx. On Oct. 29 the two pieces of the jaw were in 
contact, though not united ; there was still slight discharge 
through the opening into the mouth, but this healed up by 
Nov. 4. 

On Nov. 8 the patient was sent to Eastbourne, and 
returned to London on Dec. 11, when he was seen at the 
hospital. He was very cheerful, and very pleased with the 
result of the operation. He was able to drink out of a feeder, 
and swallow without difficulty. The two pieces of the jaw 
were in close contact, and only very slight movement could 
be obtained between them. Patient could make himself 
understood, though his articulation was very indistinct. 
The chin was behind the upper jaw, but the clisfigurement 
was not very conspicuous. There was no recurrence of the 
growth, and no enlarged glands under the jaw. He had had 
no return of the occipital pain. 



470 APPENDIX OF CASES. 

The growth was examined by Mr. Gould, and found to be 
undoubted epithelioma, cylindrical processes of large oval 
fleshy epithelial cells being seen, without any of the ordinary 
concentric " globes" of cells, though in the above-described 
cylinders a concentric arrangement of some of the cells in 
the middle, approaching that of the " globes," was found. 
This tissue was found under the tongue, just extending up 
into it ; in the gums, and extending back quite to the line of 
removal. This patient was perfectly well in Nov. 1883. 

Case XVI. — E})it]ielioma involving the Chin and Loioer Jaio — 
Removal of Growth hy section of hone and galvanic icraseur, 
ivithout opening the mouth — Beeovcry. Under the care of 
the AuTHOE. 

T. E., aged fifty-five, a fisherman, admitted Nov. 6, 
1875. In February, 1872, he had an epitheliomatous growth 
on the lower lip removed at the Monmouth Hospital, and he 
recovered completely from the operation. But twelve months 
ago — November, 1874 — he noticed a small hard lump under 
the lower jaw, to the left of the symphysis ; this lump gradu- 
ally increased in size, and in August, 18? 5, it ulcerated at 
one spot ; poultices were then applied, but more ulcers ap- 
peared. From that time the growth rapidly increased, and 
was the seat of constant pain. 

On admission, the patient was a dark, healthy-looking, 
strong man, though he stated that he had lost fiesh lately. 
There was a rounded tumour fixed to the left side of the 
body of the lower jaw, about the size of a small cocoa-nut, 
measuring six inches by five and a half, extending two and 
a half inches to the right and three and a half inches to the 
left of the middle line, reaching down to the hyoid bone. 
Most of the skin over the tumour was adherent to it, but it 
was free at the edge ; the surface was lobulated, firm, and 
elastic ; and on the under part there were six openings in 
the centre of projecting nodules, from which a stinking fluid 
escaped. There was a linear cicatrix on the left side of the 
lower lip. No part of the growth could be detected from the 
mouth ; the alveolus of the jaw was not enlarged. There 
was no dyspnoea nor dysphagia. 

Nov. 10. — The patient was put under the influence of 
cldoroform, and Mr. Heath proceeded to remove the tumour. 
He first made a curved incision over the back of the tumour 
beyond the line where the skin was adherent, and dissected 



EPITHELIOMA OF THE LOWER JAW. 471 

this off the tumour quite readily. He then united the ends 
of this incision by a straight cut along the body of the jaw. 
The body of the jaw to which the tumour was attached was 
then sawn through below the alveolus, and without wound- 
ing the mucous membrane of the mouth. An additional piece 
of bone was then removed from the left angle of the jaw 
with the bone forceps. The galvanic ecraseur was then 
applied in the lines of incision, and the mass removed in 
nine minutes. The tissue about the tyoid bone was white 
and opaque, and was therefore freely cauterized with the 
heated ecraseur. The submaxillary and sublingual glands 
and the hyo-glossus muscles were freely exposed in the 
wound, and looked healthy. The wound was washed out 
with solution of zinc chloride, twenty grains to the ounce, 
and lint dipped in this was applied, and kept in place by 
cotton-wool and a bandage. 

The patient slept well through the night, being perfectly 
free from pain, but only able to swallow liquids ; the next 
morning his temperature was 100° Y. ; pulse 96. In the 
evening the lint was removed from the wound, and a dressing 
of carbolized oil applied. His temperature gradually fell, 
and on Nov. 15 it was 98-3°; pulse 84. The submaxillary 
gland and the tissue about the hyoid bone were seen to be 
sloughing ; the upper part of the wound was granulating ; 
complained of headache. The next two days an oakum 
fomentation was applied to hasten the separation of the 
sloughs, and on Nov. 18 the surface was quite clean except 
over the submaxillary gland, and the headache quite gone. 
On the 22nd the wound was dressed with red lotion ; the last 
slough had come away ; the wound was two-thirds its 
previous size. Patient could swallow solid food well. On 
the 2Gth five skin-grafts were put on. On Dec. 2 twelve 
more were put on ; the granulation was much slower over 
the site of the submaxillary gland than elsewhere. On Dec. 8 
the wound was about one-third the size it was originally ; 
the granulations were pale and Habby, edges firm and rather 
callous ; to be dressed with a solution of nitrate of silver, 
two grains to the ounce. 

The wound continued to heal well, and the patient gained 
strength and lost all pain, which had not returned since 
the operation. There was no appearance of any recurrence 
of the growth several weeks after the operation. The patient 
went home on Dec. 23 with the wound nearly healed. 

Examination of Tumour (by Mr. Gould). — " The tumour is 



472 APPENDIX OF CASES. 

very lirmly adherent to the section of the body of the jaw, 
hut the bone looks healthy, the line of it being unbroken. 
On cutting into the under surface of the tumour, a cavity 
as large as an ordinary apple is opened, full of fetid ichorous 
fluid, with irregular walls in which are six sinuses. Ex- 
amined microscopically, the growth is seen to he a typical 
example of globular epithelioma ; this tissue extends quite 
to the lower edge of mass removed (by hyoid bone), but 
is half an inch from the surface in front (where attached to 
jaw).'; 

This, though a formidable-looking case, was a remarkably 
favourable one for operation, the disease, although extensive, 
involving none of the lymphatic glands at the angle of the 
jaw or in the neck. By sawing o& the chin, without opening 
the mouth, the whole of the bony attachment of the growth 
was isolated, and the subsequent removal of the soft tissues 
down to the hyoid bone with the galvanic ecraseur was 
entirely bloodless. The patient made a thoroughly good 
recovery, and it was hoped had been effectually relieved, at 
least for a lonij time. 

The disease recurred and the patient died some months 
after. 



INDEX 



Abscess after fracture .... 
„ of jaw ..... 
„ of antrum .... 

Adams, Mr. W., on cysts of antrum 
,, Dr. R., on cysts of lower jaw . 

Alveolus, fracture of ... . 

Amaurosis from diseased antrum . 

Ankylosis of tem|_ioro- maxillary joint . 

Antrum, diseases of 
,, suppuration in 

,, dropsy of 
„ cysts of . 

„ epithelioma of 
,, polypus of 

,, falling in of . 

Articulation, temporo-maxillary, diseases of 

Author's case of fractured alveolus 
„ „ necrosis of lower jaw 

,, „ hyperostosis of jaw . 

„ ,, dentigerous cyst 

„ „ cystic sarcoma of lower jaw 

,, „ multilocular cystic tumour 

„ „ odontoma . 

„ ,, hypertrophy of gums 

,, ,, epulis .... 

„ ,, tumour of palate 

,, ,, epithelioma of gums . 

„ „ „ antrum 

„ „ fibroma of upper jaw 

,, ., enchondroma of upper jaw 

,, „ osteoma ,, ,, . 

„ „ round-cell sarcoma of upper jaw 

„ ,, epithelioma „ „ 

,, „ ivory exostosis of lower jaw 

„ „ spindle-cell sarcoma of lower jaw 

,, „ myeloid of both sides „ ,, 

„ „ chondro-sarcoma „ „ 

„ „ ossifying sarcoma „ „ 

„ „ medullary sarcoma „ „ 



PAGE 

. 20 

. 99 

. 159 

. 172 

. 199 

1, 17, 66 

. 148 

. 413 

. 152 

. 159 

. 168 

. 171 

. 257 

. 174 

. 177 

. 412 

. 17 

118, 128 

. 149 

. 192 

203, 210 

205, 207 

. 221 

. 230 

. 241 

249, 253 

. 256 

. 257 

. 267 

. 269 

. 278 

. 305 

309, 312 

. 341 

. 348 

. 360 

. 362 

. 365 

. 370 



474 



INDEX. 



Author's case of epithelioma of lower jaw . 

„ „ „ of chin . . 

,, „ „ of gland adherent to jaw 

„ „ Esmarch's operation for closure 

„ „ closure of jaws treated with shields 

„ „ disease of temporo-maxillary joint 

„ „ hypertrophy of neck of condyle 



Bean's interdental splint 

Beaumont, Mr., enchoudroma of lower jaw 

Boinet, M,, post-mortem examination after Esmarch's 

Broca, M., on odontomata .... 

Bryant, Mr., necrosis of inter-maxillary bones 

Butcher, Mr., on cysts of lower jaw 

,, „ vascular tumour of upper jaw 

Canceb, osteoid, of upper jaw 
„ of upper jaw . 
„ of lower jaw .... 
Cannon-ball, injury to jaws by 
Canton, Mr., myeloid tumour of upper jaw 
Cap for fractured jaw . 
Caries of jaw ..... 
Cartilaginous tumours of upper jaw . 

,, „ lower jaw 

Cattlin, Mr., on the antrum . 
Chalk, Mr, 0., deformity of jaw . 

„ „ reproduction of teeth . 

Chin, silver 

Chondro-sarcoma of upper jaw 
„ „ lower jaw 

Closure of the jaws .... 
Coates, Mr., myeloid tumour of upper jaw 

,, ,, epithelioma of lower jaw . 
CoUis, Mr., enchondroma of upper jaw 
Complications of fractured jaw . 
Condyle, fractured neck of . 
Congenital dislocation .... 
Cork wedges for fractured jaw 
Couper, Mr., case of old dislocation 
Craven, Mr., medullar}^ sarcoma of upper jaw 

,, ,, myeloid of lower jaw 
Curling, Mr., epithelioma of palate 
Cystic sarcoma 
Cysts of antrum . 



of teeth 
dentigerous 
in lower jaw 
mnltilocular of lower jaw 



DEroKMiTiES of the jaws 
Dentigerous cysts 
Dentinal tumours . 



PAGE 

. 372 

. 375 

. 377 
400, 401 

. 409 

. 414 

. 420 



operation. 



48 

333 

404 

217 

. 114 

. 211 

. 298 

. 300 

. 307 

. 372 
72,80 

. 293 

. 43 

. 108 

. 268 

. 334 

. 152 

. 429 

. 113 

. 80 

. 300 

. 361 

. 388 

. 296 

. 376 

. 276 

. 15 
12,19 

. 93 

. 42 

. 91 

. 303 

. 359 

. 251 

. 202 

. 171 

. 178 

. 183 

. 181 

. 196 

. 428 

. 183 

. 217 



INDEX. 



475 



Diagnosis of tumours of upj^er jaw 

„ ,, lower jaw 

Dislocation of teeth ... 

„ with fracture .... 

„ of jaw 

„ „ symptoms of 

„ „ old standing 

„ „ rare forms 

„ ,, congenital 

„ „ treatment of . . 

Dropsy of antrum 

Duka, Dr., case of ivory tumour of upper jaw 

Enchondrojia of upper jaw 
„ lower jaw 

Epithelioma of gums . 
„ of antrum 
Epulis .... 

„ myeloid 

„ giant-celled . 

„ epitheliomatous . 

„ table of cases of . 

„ treatment of 
Esmarch, Professor, on closure of jaws 
Extraction of teeth causing fracture 

Falling in of antrum . 
False joint after fracture 
„ treatment of 
Fearn, Mr., dentigerous cyst 
Fergusson, Sir W., case of hyperostosis 
„ case of hydrops antri 

„ cysts in lower jaw . 

„ odontoma 

„ epithelioma . 

„ ivory tumour oi" upper jaw 

„ myeloid tumour of lower jaw 

Fibrous tumours of upper jaw 
„ lower jaw 

Forceps, Fergusson's . 
„ Liston's . 
„ Stromeyer's . 
Forget, Dr., on dentigerous cysts 

„ on odontoma 

Four-tailed bandage 
Fracture of lower jaw . 

„ „ museum si^ecimens of 

„ „ symptoms of 

„ ramus of lower jaw . 

„ neck of condyle of lower jaw 

„ coronoid process 

„ of lower jaw, complications of 

,, teeth .... 



PAGE 

314 

379 

16 

22 

83 
88 
90 
92 
93 
93 
168 
284 

268 
334 
254 
257 
235 
236 
237 
237 
239 
244 
393 
2 

177 

25 

53 

188 

146 

170 

183 

217 

255 

280 

359 

261 

327 

246 

245 

95 

189 

218 

33 

1 

4 

8 

11 

12 

14 

15 

16 



476 



INDEX. 



Fracture of alveolus 

„ of glenoid cavity 

„ of lower jaw, treatment of 

„ of ujiper jaw .... 

„ complications of . , . 

Gensoul on removal of upper jaw 
Giraldes, M., on cysts of antrum . 
Goodwillie, Dr., on temporo-maxillary disease 
Graefe's apparatus for fractured upper jaw 
Gross, Dr., on closure of jaws 
Growths within antrum 
Gums, diseases of . 

,, epithelioma of . 

„ hypertrophy of . 

" polypus of . 

,, papilloma of 
Gunning's interdental splints 
Gunshot injuries of jaws 
Gutta-percha splint 

„ wedges for fi-acture 

HAEMORRHAGE after fracture . 
Hamilton's sling for fracture. 
Hammond's wire-sphnt 
Harrison, Mr., odontoma 

,, ,, deformity of jaws 

Hart, Mr., necrosis of upper jaw 
Hay ward, Mr., cap for teeth . 
Hepburn, Mr., case of angular union 
Hill, Mr. B., modification of Lonsdale's splint 
Hilton, Mr., ivory tumour of upper jaw 
Holt, Mr., recurrent fibroid of lower jaw 

„ closure of jaws .... 

Humphry, Dr., prolapse of tongue, producing 
Hydrops antri . . . , 
Hyperostosis .... 

Hypertrophy of gums . 

„ neck and condyle 

Inflammation 

Interdental splint (Gunning's) 

„ „ (Bean's) . 

Irregular union after fracture 

Ivory tumour of upper jaw . 

„ ,, lower jaw . 

Jaws, gunshot injuries of 
„ infiammation of . 
,, abscess of . 
,, periostitis of 
., caries of . . . 
„ necrosis of . 



defori 



ity of 



jaw 



PAGE 

17 
19 
33 
56 
61 

816 
171 

421 

64 

391 

174 

227 

254 

227 

232 

234 

44 

66 

34 

42 

15,62 

36 

36 

220 

431 

117 

43 

21 

51 

279 

352 

406 

428 

168 

142 

227 

418 

98 
44 
48 
24 

279 
340 

66 

98 

99 

106 

108 

110 



INDEX. 



477 



Jaws, necrosis 


of, exanthematous 


. 






. 114 


„ „ syphilitic .... 






. 120 


„ „ pliosiDliorus .... 






. 122 


„ deformities of 






. 428 


Jaw, upper, fractures of 






. 66 


,, treatment of . 






. 62 


„ tumours of 






. 260 


„ „ fibrous .... 






. 261 


„ 


, cartilaginou.s . 






. 268 


J, 


, osseous . . . . 






. 277 


» 


, spindle-cell sarcoma 
, recurrent fibroid 






. 287 
. 290 




, myeloid sarcoma 






. 292 


" 


, vascular . . . . 
, chondro-sarcoma 






. 297 
. 300 


>> 


, ossifying sarcoma . 
, round-celled sarcoma 
, epithelioma 






. 300 
. 302 
. 307 


» 


, diagnosis of . 
, prognosis of 








. 314 
. 315 




, opei'ations on 








. 315 


Jaw, lower, fractures of 








1 


„ „ treatment of 








. 33 


„ „ suture of . 








. 39 


„ dislocation of 








. 83 


„ cysts in . . . 








. 181 


„ tumours of . 








. 327 


„ ,, fibrous 








. 327 


„ „ cartilaginous 








. 334 


„ „ osseous . 








. 340 


,, „ spindle-celled s 


arcoma 






. 344 


„ „ recurrent fibroid 






. 352 


,, ,, myeloid sarcoma 






. 357 


„ „ chondro-sarcoma . 






. 361 


„ „ ossifying sarcoma . 






. 364 


„ „ round-celled sarcoma 






. 369 


„ „ epithelioma 






. 372 


„ „ diagnosis of 






. 379 


„ operations on ... . 






. 380 


Lawsok, Mr., recurrent fibroid of upper jaw 






. 291 


„ ,, „ lower jaw. 






. 354 


„ „ encbondroma of lower jai 


V 




. 337 


Ligature of teeth 






. 35 


Liston, Mr., case of large epulis . 






. 242 


„ fibrous tumours of upper jaw . 






. 262 


Lonsdale's splint ...... 






. 50 


Lower jaw, fracture of . .... 






1 


„ dislocation of ... . 






. 83 


„ tumours of (see Tumours) 


M/vcGiLLiVRAY, Mr., hypertrophy of gum 229 


Maisonneuve ( 


DU dislocation , 


, 


, 


. 


. 85 



478 



INDEX. 



Margetson, Mr., case of fracture and dislocation of tooth . . 17 

Medullary tumour of upper jaw ....... 302 

„ „ lower jaw 369 

Moon, Mr., splint for fracture ....... 53 

Multilocular cysts of lower jaw 196 

„ cystic tumour . 205 

Myeloid epulis 236 

„ sarcoma of upper jaw 292 

„ „ lower jaw ....... 357 

Neck of condyle fractured 12,19 

Necrosis of jaw .......... 110 

„ exantliematous ......... 114 

,, syphilitic 120 

,, phosphorus 122 

„ symptoms of . . . ...... 124 

„ repair after ......... 127 

„ treatment of . ........ 137 

,, after fracture 20 

,, „ of symphysis 22 

Nelaton, on dislocation. 86, 95 

Neiiralgia after fracture 17, 62 

Nicholson, Mr., necrosis of alveolus 112 

Non-union of fracture ........ 25 

Odontomata 217 

Old-standing dislocations 90 

Operations on upper jaw 315 

„ lower jaw 380 

Ossifying sarcoma 300, 364 

Osteoma of upper jaw 277 

„ lower jaw 340 

Paget, Sir J., polypus of antrum . . .... 175 

Palate, tumours of the . . 248 

Paralysis of dental nerve . . . . . . . 17, 62 

Periostitis of jaw 106 

Permanent closure of jaws 390 

Phosphorus-necrosis 122 

Poly j)us of antrum 174 

Eamus of lower jaw fractured 11 

Recurring-fibroid of ui:)per jaw 290 

„ „ lower jaw . 352 

Repair after necrosis 127 

Rheumatoid arthritis, temporo-maxillary 415 

Rizzoli, on closure of jaws 397 

Saliyakt fistula after fracture 20 

Salter, Mr., case of fractured upper jaw . ... 56 

„ on exanthematous necrosis ..... 114 

„ on dentigerous cysts 185 

„ on odontomata 223 



INDEX. 



479 



Salter, Mr,, on hypertrophy of gum . 

„ on papilloma of gum 

Savory, Mr., on repair after phosphorus-necrosis 
Shillito, Mr. B., fibrous tumour of lower jaw 
Smith, Mr. Cox, case of gunshot injury of upper j 
„ „ case of injury to symphysis 

„ Prof. R. W., on dislocation 
,, Mr. T., on phosphorus-necrosis 
Spasmodic closure of jaws . 
Specimens of fractured jaw 
Splint, interdental (Gunning's) . 

„ „ (Bean's) 

„ Lonsdale's 

„ „ Hill's modification 

„ for lower jaw . 
Square, Mr., enchondroma of upper jaw 
Stromeyer's forceps 
Sub-luxation of jaw 
Sub-periosteal resection 
Suppuration in antrum 
Suture of lower jaw 
Syme, Mr., tumour of hard palate 

„ „ osteo-sarcoma of lower jaw 
Symphysis, necrosis of 
Symptoms of fractured jaw 
Syphilitic necrosis 

Tay, Mr. W., necrosis of lower jaw 
Teeth, fracture of . . . 

„ dislocation of . 

„ ligature of . . . 

,, tumours connected with . 
Temporo-maxillary articulation, diseases of 
Thomas's wire-suture . 
Tomes, Mr., on hypertrophy of gums 

„ „ dentigerous cysts . 

„ „ odontomata 

Treatment of fractures of lower jaw 
„ „ _ upper jaw 

Tumours connected with teeth 

„ papillary, of gum . 

„ of palate 

„ of upper jaw. 

„ ,, fibrous 

„ „ cartilaginous 

„ „ osseous 

J, „ spindle-celled sarcoma 

„ „ recurrent-fibroid 

„ „ myeloid . 

„ „ vascular 

„ ,, malignant . 

J, „ diagnosis of 

„ treatment of 



FASB 

227 

234 

128 

330 

70 

11 

89 

130 

388 

4 

44 

48 

60 

51 

34 

275 

95 

415 

139 

159 

38 

248 

348 

22 

8 

120 

115 

16 

16 

35 

214 

412 

39 

231 

186 

217, 222, 225 
33 
62 
214 
234 
248 
260 
261 
268 
277 
287 
290 
292 
297 
302 
314 
315 



480 



INDEX. 



Tumours of lower jaw . 

„ „ cystic-sarcomatous 

„ „ fibrous 

„ „ cartilaginous 

„ „ osseous 

„ „ spindle-celled sarcoma 

„ „ recurrent-fibroid. 

„ „ myeloid 

„ „ malignant. 

„ „ diagnosis of 

,, „ treatment of 

UmoN of fracture after necrosis . 

„ irregular, of fractured lower jaw 
United States' Army Museum, specimens of gunsliot 
Ununited fracture of lower jaw . 

„ ,, treatment of 

UjDper jaw, fractures of . . . 
„ tumours of [see Tumours) 



Vascular tumours of upper jaw 
Vasey, Mr., deformity of jaw 
Verneuil, M., on closure of jaws . 

Warken, Dr. Mason, on cysts of lower jaw 
Weiss, Mr. F., closure by cicatrix 
Wells, Sir S., fibrous tumour of lower j;iw 
Wheelhouse's method of wiring jaw 
Wilkes, Mr., epithelioma of lower jaw 
Wire splint, Hammond's 
Wiring lower jaw .... 

Wounds of the face .... 



injury m 



FAGB 

327 
202 
327 
334 
340 
344 
352 
357 
369 
379 
380 

21 
24 
76 
25 
53 
56 



297 
430 
400 

211 

405 

328 

40 

376 

36 

39 

15 



Appendix of Cases 



434 



THE END. 



CALLANTYNE PRESS, CHANDOS STREET, W.C. 



* . ,> UNIVB«SITY OF (CALIFORNIA LIBRARY 

Los Angeles 
' This book is DUE on the last dajte stamped below. 



UEO 6 1955 



Form L9-116m-8,'62(D1237s8)444 



Keath, C. 

Injuries and diseases 
of the jaws. 3d ed. 



^ I - 



IL^ 



-''Jtr' :j%;i 



/'V" LI BR AH Y '^^ 

20& c.. 2cJr(1 SI .